Family Medicine - Wonca Europe

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medical education and training and supports the idea to establish Family Medicine as the leading ...... respect by the community grocer or by the car mechanic.
The World Book of

Family Medicine -

European Edition Published on the occasion of the 20th Anniversary of

WONCA Europe Istanbul, October 2015

World Book of Family Medicine – European Edition 2015

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World Book of Family Medicine – European Edition 2015

First Edition 2015 (published by Stichting WONCA Europe) World Organization of Family Doctors - Europe (WONCA Europe) Polsjanski Nasip 58, 1000 Ljubljana, Slovenia © 2015 Stichting WONCA Europe and the Authors Stichting WONCA Europe has asserted its right under the Copyright, Designs and Patents Act 1988 to be identified as the author of this work. Every effort has been made to ensure that the information in this book is accurate. This does not diminish the requirement to exercise clinical judgement, and neither the publisher nor the authors can accept any responsibility for its use in practice. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. Requests for permission to reproduce or translate WONCA publications for commercial use or distribution should be addressed to the WONCA Secretariat at [email protected] The Authors remain the sole copyright owners of their conribution. Design: Carl Steylaerts Available online at http://www.woncaeurope.org/sites/default/files/world book 2015.pdf Printed in Turkey on 2000 copies Paper copy: CIP - Kataložni zapis o publikaciji Narodna in univerzitetna knjižnica, Ljubljana 614.2:316.356.2 The WORLD book of family medicine. - European ed. - Ljubljana : Stichting WONCA Europe, 2015 ISBN 978-961-281-983-5 Electronic copy: CIP - Kataložni zapis o publikaciji Narodna in univerzitetna knjižnica, Ljubljana 614.2:316.356.2(0.034.2) The WORLD book of family medicine [Elektronski vir]. - European ed. - El. knjiga. - Ljubljana : Stichting WONCA Europe, 2015 Način dostopa (URL): http://www.woncaeurope.org/sites/default/files/42.pdf ISBN 978-961-281-984-2 (pdf) This book uses British English as the language for carrying thoughts. Proofreading was performed by Ms Naomi Uludamar.

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World Book of Family Medicine – European Edition 2015

Table of Contents Prologue

Mehmet Ungan, Carl Steylaerts

8

Andrée Rochfort

10

1

Patient Empowerment for Patient Self-Management

2

Communicating with Patients

Michael Jones

13

3

Ethical Problems in Family Medicine

Manfred Maier

15

4

Health Consequences of Emotional, Physical and Sexual Abuse

Lucy Candib

18

5

The Role of Family Medicine in Undergraduate Medical Education

Zekeriya Akturk

21

6

Developing National Curricula for the Education and Training of Family Doctors

Jessica Watson

25

7

Transient Illnesses

Ignaas Devisch

28

8

Cooperation Across the Interface of Primary and Secondary Care

Odd Jarle Kvamme

30

9

Complexity and Primary Care

Joachim Sturmberg

33

10

Motivational Interviewing in Family Medicine

Siggy Rausch

37

11

Quality Circles

Adrian Rohrbasser

40

12

Pathology and Minor Surgery in Primary Care

Pieter Buis

43

13

Developing Research Capacities in Family Medicine: the Croatian Experience

Mladenka Vrcic

46

14

An International Comparison of the Role of the Family Doctor in Different Countries

Donatella Sghedoni

49

15

Tackling Health Inequalities: the Role of Family Medicine

William Wong

52

16

Using the Internet to Answer Clinical Questions

Harris Lygidakis

56

17

Threats to Patient Safety in Primary Care

John Sandars

59

18

Teaching uncertainty

Yona Yaphe

61

19

Home Visits: a Medical Necessity or Simply a Service?

Paul Van Royen

64

20

Promoting the Health and Well-being of Family Doctors

Ulrich Busch

67

21

Prevention and Health Promotion in Clinical Practice

Carles Brotons

70

22

Determinants of Multi-morbidity

Marjan van den Akker

73

23

When Chronic Care Becomes End-of-Life Care: Bridging the Gap

Radost Assenova

76

24

What is Universal in Primary Care? Challenges for North/South Co-operation.

Matie Obazee

79

25

The New Consultation: The Doctor in the Electronic Age

Theo Schofield

82

26

How to Deliver a Successful Learning Package for Family Medicine Trainees?

Jaime Correia de Sousa

85

27

The Integration of Mental Health into Primary Care: International Perspectives

Filippo Zizzo

88

28

WONCA and the Cochrane Primary Health Care Field

Floris A. van de Laar

91

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World Book of Family Medicine – European Edition 2015

Table of Contents 29

Do you Understand How Your Health System Works?

Sietse Wieringa

94

30

The Transition from CME to CPD – Fostering Good Practice Through Education

Francine Lemire

97

31

Factors Associated with Adherence to Drug Therapy

Annika Bardel

100

32

Improving Practice Questionnaire - A Patient Feedback Tool

Michael Greco

103

33

Health Promotion in European Family Practice

Ursula Reichenpfader

105

34

How the UK Discovered Europe

Justin Allen

108

35

Health Needs Assessment

Claire Collins

110

36

The Balint Experience

John Salinsky

113

37

Environment and Health in Family Medicine

Alan Abelsohn

115

38

Mentoring - a Quality Approach to Professional Development

Karen Bentley

118

39

Pleasures of Doctoring in Family Medicine

Andre Matalon

121

40

Measuring Effectiveness in Family Medicine

Teresa Pawlikowska

124

41

The International Classification of Primary Care: a Success Story

Jean Karl Soler

127

42

Physician Heal Thyself and then the World

Janet Christie-Seely

129

43

Competency in Medical Record-Keeping

David Bazzo

132

44

The Health Needs of Hard to Reach Groups: Do We Know Enough?

Erika Zelko

135

45

Is There Such a Thing as a Correct Diagnosis in Family Medicine?

Tor Anvik

138

46

Family Medicine Facing the New Challenges at a Global Scale.

Jan De Maeseneer

142

47

The Educational Agenda

Esra Saatchi

145

48

Continuity in Primary Care

Francesco Carelli

148

49

Where Family Medicine Meets Public Health

Francois Schellevis

151

50

Stages of Behavioural Change – a Helpful Concept for Family Doctors?

Norbert Donner-Banzhoff

154

51

Future and Innovation in Family Medicine

Carl Steylaerts

156

52

Home Care at the Dawn of the 21st Century

Elias Papazissis

160

53

To Travel With Your Profession Is to Live and Learn

Per Kallestrup

163

54

Am I a Good Doctor?

Hrvoje Tiljak

166

55

Evidence-based Primary Care Through Guidelines

Marjukka Makela

169

56

Developing Skills for the Developed World

Christos Lionis

172

57

Gut Feelings as a Guide in the Diagnostic Reasoning of GPs

Erik Stolper

174

58

Family Medicine Miles Program

Pablo Blasco

178

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World Book of Family Medicine – European Edition 2015

Table of Contents 59

Improving the Prescribing of Antimicrobial Drugs in Primary Health Care

Carl Llor

181

60

Comprehensiveness and Continuity of Care

Heinz-Harald Abholz

184

61

Teaching Cross-Cultural Care

Constantinou S. Costas

187

62

How to Recruit and Select Your Future Colleagues?

Monica Lindh

190

63

Motivate Healthy Habits For Life: Coach Each to Change

Rick Botelho

193

64

An Ideal Training for the Future Career Patterns of Family Medicine

Mark Rickenbach

197

65

Burn Out and Family Practice

Fatma Goksin Cihan

199

66

Assessing Patient Satisfaction in Primary Health Care

Risto Raivo

202

67

Risk, Uncertainty and Indeterminacy in Clinical Decisions

Roger Strand

205

68

Do Practice Visits Have a Future?

Pieter van den Hombergh

208

69

Contribution of Drugs and Somnolence to Car Accidents with Victims

Paul Moeremans

211

70

Involve Patients With Doctors in Safety Improvement

Isabelle Dupie

214

71

The Optimal Practice Size Revisited – a Critical Appraisal of a Topical Discussion

Chris van Weel

217

72

Revisiting “Home Visits: Your Practice on the Road”

Rita Viegas

220

73

Re-training of Family Doctors: A EURACT Survey

Fusun Yaris

223

74

Primary Care Based Case-management

Tobias Freund

226

75

How Would Citizens Develop the Health Strategy of Their Country?

François Héritier

229

76

Drafting A Practice Professional Development Plan

Alexandre Gouveia

232

77

European Practice Assessment (EPA)

Joachim Szecsenyi

235

78

The Role of The Royal College of General Practitioners (UK)

Nigel Mathers

239

79

From Familygram to Personalised Medical Care

Tonka Poplas-Susic

241

80

The Growth of the Guideline

Felicity Goodyear-Smith

244

81

Developing Culturally Sensitive Services in Primary Care

Victoria Tkachenko

247

82

The MRCGP International - Developing a Truly Contextual Assessment

John Howard

250

83

Do we Practice what we Preach ?

Judit Simon

253

84

Helping Family Physicians in Managing Families With a Difficult Child

Luc Lefebvre

256

85

Family Systems Medicine

Raluca Zoitanu

259

86

Assessment of the Professional Attitude of Family Doctors

Isabel Santos

262

87

Family Medicine and Sustainability

Giuseppe Maso

265

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World Book of Family Medicine – European Edition 2015

Table of Contents 88

How to Build an Ideal Healthcare Information System?

Ilkka Kunnamo

268

89

Making Sense of Chronic Disease

Merete Jorgensen

271

90

A Practical Approach To Teaching Medical Students About Community Services

Karen Flegg

273

91

New Technologies to Support Family Doctors

Berk Geroglu

277

92

Patients' Rights and the Views of Family Doctors

Maria Dolores Perez

280

93

About Quaternary Prevention: First, do no harm.

Marc Jamoulle

283

94

War – Terrorism – Ethical Challenges and Family Physician Education

Nazan Karaoglu

286

95

Parents of a New-born Child with Severe Disabilities

Anette Hauskov Graungaard

288

96

Family Doctors' Career Towards Academic Level: Why and How

Igor Svab

292

97

A European Observatory for Primary Care Development

Robert Glendenning

295

98

New Era for Clinical Research in Primary Care

Knut-Arne Wensaas

298

99

Family Therapy Skills for Medical Practitioners

Radkin Honzák

301

100

What We Do

Richard G Roberts

303

Michael Kidd, Job Metsemakers

306

Epilogue as Prologue Acknowledgements

307

20 Years of WONCA Europe - Some History

308

In close collaboration with our networks

Vasco da Gama Movement

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World Book of Family Medicine – European Edition 2015 Mehmet Ungan, MD [email protected] Carl Steylaerts, MD [email protected]

Prologue Conceiving of a World Book of Family Medicine is easy. Actually making one is a lot harder. We started in 1995 and 20 years later, we present you this present in the present. It contains a lot of history and the roots for a lot of future plans. We leafed through 20 years of abstracts, including those presented at World Conferences, made a long list, selected a jury who then made a short list of 100 titles that best represented our job. During this process, it became obvious that we had selected mostly European titles, hence, this is the European Edition of the World Book. We do hope that other regions will follow, and also hope that a following generation will create The World Book of Family Medicine. Time will tell. In the process of finding the original authors, some were lost due to natural causes – death, illness, retirement. We then went to find body-doubles, and it will be no surprise that a lot of the youngsters of the Vasco da Gama Movement are authoring themes that were researched almost before they were born – offering a splendid proof that memory is a living organism that is constantly recreated and growing. We owe a lot to the 100 authors who finally drafted their 1000 words, selected take home messages and showed us the sources of their thoughts, with references. They were put under time pressure, some had to redraft, and then everything was being proofread by our outstanding Miss Naomi Uludamar. We owe her so much. All the authors joined us in a journey towards … a growing body of evidence that WONCA and WONCA Europe inspire, teach and learn. We show them our eternal gratitude and honour them. Thank you all! While editing this World Book, it became also obvious that there is no such thing as one kind of General Practice or Family Medicine. There is only a local answer to local needs. And though General Practice/Family medicine is mostly a clinical specialty, you will find none of this in this book. For then we should have taken 1000 titles. The chosen titles should be regarded as “generic”, applicable in every country – or at least most of them. This book is a starting point. WONCA (Europe) is the terrific place where knowledge about our field of experience, expertise and interest is exchanged. Youngsters come for a try out, PhD students lecture from their research, post docs idem, seasoned professors tell us their stories, and key note speakers from various fields come to inspire us. Hypes come, hypes go. Some stay, as evidence based medicine – not as a golden bullet, but as an enrichment. The past 20 years brought us a lot of change and some of that wisdom changed our daily work. To be true, this book is about people. The people that we care for, our patients, and the people that we care for, our colleagues. The reason why we make the journey to the different places, mostly terrific as well, where the Conferences take place. The more you go to a conference, the less you learn, but the more people you get to know. And their 8

World Book of Family Medicine – European Edition 2015 stories, which is why every Conference is a rich environment. Then bad news arrived. Soon after she finished her contribution, Professor Fusun Yaris died, a lost battle. A few weeks later, another author, Professor Janko Kersnik had an appointment with the Great Reaper as well. It makes us aware of our mortality. And the legacy that this book bears. The myth of Zeus and the birth of Athena comes to mind. A quantum of solace for us, earthlings. Fusun and Janko went early, we will follow one day. Theirs and ours and your energy however will not disappear. Our genes live in a trans-, inter- and intragenerational environment. And as we now know, both Darwin and Wallace were right. So it is important to keep digging for ideas, knowing that they will mutate and differentiate as well. It is in that great tradition of creating fora for exchanging ideas that we found the inspiration for this World Book. One author referred to the famous words of Margaret Mead: Never underestimate the power of a few committed people to change the world. Indeed it is the only thing that ever has.

Take home messages 

The proof of the pudding however is in … the reading.



We hope you enjoy this World Book – European Edition.



And that we inspire others to follow and do even better.

Ex Oriente Lux! Prof Mehmet Ungan, MD Professor of Family Medicine Editor

Carl Steylaerts, MD Hon Treasurer WONCA Europe Co-Editor

Istanbul, October 2015

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World Book of Family Medicine – European Edition 2015 Andrée Rochfort, MD [email protected]

1 – Patient Empowerment for Patient Self-Management Wonca Europe 20th Anniversary Project 2015 Andrée Rochfort, MD Project Leader: Patient Empowerment – Wonca Europe, Honorary Secretary EQuiP, Director of Quality Improvement, Irish College of General Practitioners, Dublin Project Partners: Tina Eriksson (DK), Ilkka Kunnamo (FI), Jochen Gensichen (DE), Project Manager: Claire Collins (IE) With thanks to members of the EQuiP Wonca Europe Network Patient Empowerment Group and thanks to Project Special Advisers: Ernesto Mola (IT), John Litt (AU) and Susan Smith (IE)

At the European Council meeting of WONCA Europe in Warsaw in 2011, Patient Empowerment was adopted as the twelfth characteristic of general practice in the European definition of family medicine (FM) by WONCA Europe, and categorised within the core competency of person-centred care. Core competencies of the FP doctor mean competencies essential to the discipline, irrespective of the health care system in which they are applied.

Fig 1 The WONCA TREE – as produced by the Swiss College of General Practitioners (Revised 2011) – Reprinted with permission

WONCA Europe: The European Definitions of the Key Features of the Discipline of General Practice 2011 The 2011 revision of the definition of FM gives recognition to the new dynamic between doctor and patient. As social values and healthcare systems continue to change, patients’ expectations are to make choices and decisions in keeping with their autonomy. This recent revision of the definition of FM gives the FP in Europe a new role to harness this patient autonomy and develop the expertise of patients in managing their own health and illnesses. Empowering patients is officially acknowledged as a responsibility of family medicine, which provides an appropriate

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World Book of Family Medicine – European Edition 2015 environment to promote patient empowerment for self-management of chronic conditions. In 2012 WONCA Europe sought to fund a project with the aim of having a lasting benefit for FM in Europe, and in order to prepare its report for the 20th Anniversary of WONCA Europe in 2015. The successful bid was submitted by EQuiP, The European Society for Quality and Safety in family medicine, along with three project partners; the Irish College of General Practitioners, the Finnish Medical Society Duodecim, and the Department of Family Medicine at University of Jena, Germany. The project partners sought to explore one aspect of chronic disease management, namely, patient empowerment in self-management of chronic disease. The EQuiP group initially named the project PECC-WE; Patient Empowerment in Chronic Conditions - WONCA Europe, and the project was initiated with the definition of “patient empowerment” (PE) as defined in the European Journal of General Practice (EJGP) article by Ernesto Mola: Patient Empowerment is an educational process to help or support the patient to develop knowledge, skills, attitudes and self-awareness, and to assume effective responsibility for health-related decisions. Definition of Patient Empowerment (E. Mola, EJGP 2008) The value of investing in empowering patients to help themselves seems obvious; however the brainstorming sessions in our project research group revealed that we still have questions about which specific skills, attitudes and behaviours can be taught to primary care clinicians to promote positive patient behaviours and attitudes that improve patient outcomes in chronic conditions. The project partners agreed that the best use of project funds would be to explore whether the education of clinicians in FM to improve patient empowerment for self-management of chronic conditions would improve outcomes for patients compared to patients of clinicians who were not educated in that particular skill.

The WONCA Anniversary Project 2015 The role of the family physician (FP) has changed over the last twenty years. Patients’ attitudes to health and healthcare have also changed. The revision of the European definition of general practice is a response to these changes. Patients are more informed now and have access to the same sources of information as medical doctors. Patients in 2015 are less likely to be passive recipients of healthcare and are more likely to have expectations and demands that reflect the psychology of consumer-based societies. 21 st century patients expect to receive high quality, safe care. However, as all members of society are either patients or potential patients, there is an obligation on all citizens to participate in their care and actively manage their own lifestyle factors for optimum health. Once established, chronic diseases are by definition not curable. Multimorbidity and polypharmacy are escalating as people live longer with chronic conditions. Public services funded by taxpayers and privately funded healthcare services, voluntary organisations and charities all contribute finance and other resources towards the management of chronic conditions. These challenges of healthcare provision are intensifying as costs, demands and expectations are apparently infinite, while resources remain finite. Our research shows that one path for assisting patients to improve their health outcomes is through primary care health professionals who are educated and trained in the skills of motivation, goal setting and communication skills appropriate for change management. There are of course many pathways to patient empowerment, and several factors influence patients’ motivation and capacity for self-management. We have evidence that patient self-management has a positive impact on health outcome, though we must acknowledge that incorporating self-management support in routine healthcare is in itself challenging.

In conclusion There are a number of findings of this project which will be formally presented at the WONCA Europe Conference in Istanbul, 2015. These include the systematic review report, the online educational tool for health professionals and its evaluation, and the launch of an online hub of resources on patient self-management for health professionals, patients and those who care for them. Our research findings can be regarded as a successful starting point for primary care-based multidisciplinary interventions with capacity to implement quality improvement in management of chronic conditions for the benefit of

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World Book of Family Medicine – European Edition 2015 both patients (improved self-efficacy and better outcomes), and for health professionals (improved self-efficacy and job satisfaction).

The future post 2015 This project will add to the growing evidence-base for integrating patient self-management into routine healthcare. In general practice we recognise the need to intervene earlier, even before chronic disease is established, when the person has risk factors like smoking, alcohol consumption, obesity, or cardiovascular risk due to a combination of several moderate risk factors. We hope this will prompt a fresh multifaceted interest in managing lifestyle risk factors for chronic disease in European general practice / family medicine, to reappraise our various models of chronic condition management and to ensure best practice models are disseminated. Exploring this complex topic has highlighted global issues which have an impact at grass roots level in routine general practice / family medicine. It would be encouraging to see GP/FP from all WONCA regions collaborate to develop a global team player approach in addressing the important role of the patient in determining their own health outcomes.

Take home messages 

Patients have capacity to improve their own health through patient self-management.



Patient empowerment for self-management is a core element of patient-centred care.



Primary care health professionals with training in patient self-management support can help to empower patients for change.

References 

   

THE EUROPEAN DEFINITIONS of The Key Features of the Discipline of General Practice,

The Role of the General Practitioner and a description of the Core Competencies of the General Practitioner / Family Physician. Revised in 2011 by a Commission of the WONCA European Council led by Dr Ernesto Mola and Dr Tina Eriksson. http://www.woncaeurope.org/sites/default/files/documents/Definition%203rd%20ed%202011%20with %20revised%20wonca%20tree.pdf M Battersby et al Twelve Evidence-Based Principles for Implementing Self-Management Support in Primary Care. The Joint Commission Journal on Quality and Patient Safety. December 2010 Volume 36 Number 12. Mola Ernesto, Judith A De Bonis, Raffaele Giancane, Integrating patient empowerment as an essential characteristic of the discipline of general practice/family medicine. European Journal of General Practice. 2008, Vol. 14, No. 2, pp 89-94 http://informahealthcare.com/doi/full/10.1080/13814780802423463 An De Sutter, Jan De Maeseneer, Pauline Boeckxstaens. Empowering patients to determine their own health goals. Editorial. European Journal of General Practice. 2013; 19: 75–76 Patient Empowerment in Chronic Conditions, 20th Anniversary project 2015. www.woncaeurope.org

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World Book of Family Medicine – European Edition 2015 Michael Jones, MB, ChB [email protected]

2 – Communicating with Patients Michael Jones, MB, ChB Retired, Darlington, WA – Australia

Patients want: 

Factual, authoritative information



Both sides of the story



Language they can understand



Advice they can follow

Using the newsletter: 1.

Hand it to patients

2.

Keep it topical

3.

Include personal bits and pieces

This presentation, from Western Australian GP Dr Michael Jones, was aimed at encouraging GPs to use a practice newsletter. The talk illustrated the benefits, to both patients and doctors, of using this form of communication. The speaker reminded the audience that “doctor” used to mean “teacher” and that GPs need to focus on their role as educators about health, as well as dealing with the specific issues raised at any given consultation. In 1991, frustrated by some of his patients making unwise decisions based on what they had read in the popular media, or seen on TV, Dr Jones decided to produce a newsletter for the patients of his practice. The purpose of the newsletter would be to give patients accurate information on topical medical issues, remind them about preventative health matters, and give general advice about nutrition and other health-related topics. At the same time, the newsletter would keep them informed about current activities in the practice, such as details of new doctors, practice policies, staff leave, etc. He rapidly realised the enormity of this task and hit on the idea of producing a ‘generic’ newsletter which could then be personalised for individual subscribing doctors or practices. As a result, the concept of the practice newsletter ‘Your Doctor’ was born. With the help of an experienced journalist, Dr Jones Doctors need to: produced the first edition in February 1992. It is a  Show that they care monthly 4 page A4 newsletter (one page of A3 paper  Tell patients about folded once) with articles of general medical interest, themselves and the plus reminders about preventive health measures services they provide such as pap smears, mammograms and  Make patients feel they immunisations. One segment – Good Health on the ‘belong’ Menu – contains nutritional advice plus a recipe relevant to that month’s topic.  Improve their business Areas on the front and back pages are left blank in the initial print run and then overprinted with information provided by the individual subscribing practice. Practices pay a fee which depends upon the number of copies required. The practice can change the content of its personalised section each month at no extra cost. The concept was promoted to GPs as a useful tool, benefitting both patients and doctors. Patients benefit from getting reliable information from a source they trust – their family doctor. Doctors benefit because in the competitive small-business environment of Australian general practice, where patients are free to see GPs from any practice, patient loyalty is critical for financial survival. Patients appreciate their doctor doing that little-bitextra to keep them informed and healthy. The presentation demonstrated the often sensational, out-of-perspective, manner in 13

World Book of Family Medicine – European Edition 2015 which the popular media broadcasts medical information. This may lead to patients making unwise decisions such as stopping their medication through fear of highly publicised (although rare) side-effects. Dr Jones reported on positive feedback from patients, including a lady in Victoria who had read an article about angina, recognised her symptoms, saw the GP and soon after had a triple coronary by-pass operation. She wrote and thanked her GP for “writing the article that saved my life”. He also emphasised the importance of doctors including some personal information in the practice-specific segment. This shows their human side, which patients like. When, in his own practice’s newsletter, he advised readers that he would be away for a month, as he was going to the UK for his mother’s 80 th birthday, numerous patients got in touch to wish her well, despite never having met her. Another tip was for doctors to keep the newsletter on their desk and personally hand it to patients saying “have you had this month’s newsletter?” or similar, rather than leaving it among the piles of other helpyourself brochures in the waiting room. Research shows that people are more likely to read something when it is given to them personally by a doctor. Dr Jones told of a patient coming to the reception desk and saying “I don’t need to see the doctor, but is this month’s newsletter out yet?”. In 1994 the Australian government introduced an accreditation scheme for general practices. One of the criteria for accreditation was that the practice should have a patient-information brochure. ‘Your Doctor’ was approved as a suitable means of meeting that requirement. The initiative has proved to be a great success. By the end of 2004 it had been used in over 700 Australian general practices, plus practices in New Zealand, Hong Kong and Fiji. The annual print run was about one million copies.

Original Abstract Figure 1 The first edition of Your Doctor was produced in February 1992. My 2004 it had been used in more than 700 practices with an annual print run of almost one million copies.

http://www.woncaeurope.org/content/76-pacommunicating-patients

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World Book of Family Medicine – European Edition 2015 Manfred Maier, MD [email protected]

3 – Ethical Dilemmas in Family Medicine - a Workshop Manfred Maier, MD Professor, Chairman, Dept. General Practice, Vienna, Austria; Convener of the WONCA Working Party on Ethical Issues

Background At the WONCA Europe Conference 2000 in Vienna, Austria, the programme included a special symposium entitled “challenges to our professional attitudes- past and present”. This full day symposium covered areas and time periods from the past to the present where the medical profession in general or individual colleagues have been or were involved in developments based on unique political situations: the Holocaust in Europe, the Apartheid in South Africa, torture of prisoners in areas of war or the death penalty in the United States. Experts and eyewitnesses of these developments gave stunning insight into the circumstances whereby physicians could get involved and sometimes were even eager to do so. This symposium attracted a full auditorium and resulted in the founding of a Special Interest Group (SIG) on ethical issues in Family Medicine by WONCA. In 2002 the group gathered to formulate the terms of reference: “to attempt to illustrate the nature of ethical issues encountered by WONCA and its members and to explore the principles, values and beliefs which inform decisions”. Thus, the aims of SIG were formulated: 1. 2.

To identify common principles of ethical dilemmas To consider circumstances which favour the development of ethical dilemmas

3. 4.

To raise awareness about ways to solve some of these ethical dilemmas To develop an instrument useful to assess professional attitudes

Since that time, the proceedings of the special symposium from WONCA Europe Vienna 2000 have been published (1); a list of interested colleagues has been established and the group has tried to identify Family Doctor's working groups on ethical issues around the globe. In addition, the group has reviewed the teaching situation for professional attitudes worldwide, has introduced a forum for discussion on ethical issues and tries to motivate colleagues to initiate similar activities in their associations or back in their home country. These activities are promoted at almost every WONCA Europe conference and all WONCA World conferences by organizing a workshop on “ethical dilemmas in FM” and a special symposium on “challenges to our professional attitudes” addressing selected topics such as inequalities in health, conflicts of interests, end of life care, electronic health records, etc. So far, the activities of the group, which became a Working Party (2) at the WONCA World conference 2010, have attracted a very interested crowd - at times it has been difficult to accommodate all participants in the room provided!

The Workshop In the workshop, practical situations involving regularly occurring ethical dilemmas in Family Medicine are presented 15

World Book of Family Medicine – European Edition 2015 and their background and possible consequences for the patient, his/her family and the physician are discussed. Typically, the group work starts with short presentations by the workshop participants, demonstrating situations involving ethical dilemmas. The participants then select 3-4 situations out of those presented, split into small groups and discuss the following issues: 1. The patient’s history and other factors, which resulted in the development of the particular ethical problem presented 2. 3.

The possible consequences of the situation for the patient and the physician Possible solutions

4. What are the basic ethical principles demonstrated and challenged by this situation? The aim of this workshop is to increase awareness in ethical standards, attitudes and global differences in the legal context of clinical practice applicable to future medical graduates and Family Doctors. Here are a few examples of the difficult situations presented: 

Both a woman and her husband are patients with the same family doctor. The woman receives Diazepam for anxiety and depression due to metastatic breast cancer; her husband is in early retirement and in a consultation with his Family Doctor complains about his sleepiness. Previously, the woman told the Family Doctor that in the evening she puts some of her pills into her husband's wine so that he would not sexually approach her.



A patient with a haemoglobin level of 2.4 refuses both diagnostic procedures and therapy suggested by his Family Doctor.



A sixteen year old boy suffers from heavy injuries and tetraplegia after a car accident; it turns out that he had too much alcohol in his blood. His father requests the Family Doctor to delete this information from the medical record for reasons of disability insurance coverage.



A 54 year old woman with diabetes and diabetic nephropathy needs kidney transplantation. According to the legal situation she is not entitled for a kidney transplant in her country. However, for a large fee, she is offered the kidney of a prisoner in China who is facing the death penalty. She approaches her Family Doctor for advice.



An elderly lady first refuses diagnostic clarification and therapy of her hip fracture; a few days later she agrees with the suggestion by her Family Doctor to be treated in the hospital and dies there following surgery. The Family Doctor feels guilty.



In a given country, influenza vaccination at the Family Doctor-level is obligatory for every citizen and those who refuse are punished with a 400 Euro fine; moreover, Family Doctors are legally obliged to report every patient who refuses to comply.

Among the questions quite often discussed and exchanged among participants are those related to the respective health care system, the respective legal framework, the needs and demands of patients in the country concerned, the expectations of patients and society, conflicts of interest, options for support and advice in these situations, the need for efficient communication, how to react in the particular situation, etc. Finally, the principles and responsibilities of medical professionalism (3) such as the principle of respect of patients´ autonomy, priority of patients’ welfare and of promoting social justice and equity are identified and their value and possible discrepancies in political or market reality are discussed. Despite these principles and guidelines however, the family doctor is more often than not alone in his/her decision regarding an individual situation. The WP on ethical issues in FM plans to raise awareness of the importance of professional attitudes at every level of medical education and training and supports the idea to establish Family Medicine as the leading discipline in teaching medical ethics/professional attitudes to students and colleagues. This will be accomplished through promoting widespread dialogue within the profession, initiating and supporting research and disseminating information throughout the WONCA community, the international academic community, healthcare organisations and government agencies.

Take Home Messages 16

World Book of Family Medicine – European Edition 2015 The WP workshops on Ethics described aims to: 

identify common principles of ethical dilemmas as they occur in daily practice



discuss circumstances which favour their development



to raise awareness about ways to solve and prevent some of these ethical dilemmas

Original Abstract http://www.woncaeurope.org/content/192-ethical-dilemmas-general-practice-workshop

References   

Kochen M, Rebhandl E, Maier M; Challenges to our Professional Attitudes- past and present. Verlag der Österreichischen Ärztekammer, 2001, ISBN 3-901488-22-7 http://www.globalfamilydoctor.com/groups/WorkingParties/EthicalIssues.aspx Medical professionalism in the new millennium: a physicians' charter. Medical Professionalism Project; The Lancet 2002, 359, Issue 9305: 520-522 (DOI: 10.1016/S0140-6736(02)07684-5)

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World Book of Family Medicine – European Edition 2015 Lucy M. Candib, MD [email protected]

4 – Health Consequences of Emotional, Physical, and Sexual Abuse Lucy M. Candib, MD 1, W. Perry Dickinson, MD 2, Pamela McMahon, PhD, MPH 3 1 Family Health Center of Worcester and University of Massachusetts Medical School, Department of Family and Community Medicine, Worcester, MA 2 University Colorado School of Medicine, Department of Family Medicine, Aurora, CO 3 Our Lady of the Lake Regional Medical Center, Pediatrics Residency Program, Baton Rouge, LA

Abuse is widespread across all ethnic, cultural, and socio-economic groups. In the US population, 30 - 40% of adults report some type of abuse during childhood. Different forms of abuse often co-occur. Rates of abuse in other countries are variable, but comparable. Clinicians who believe abuse does not occur in their patients are just not looking for it.

Childhood Abuse – Mental Health Impact A history of childhood abuse correlates strongly with mental health symptoms. A dose-response effect exists between multiple types and severity of abuse with magnitude of symptoms, and number of diagnoses. Post-traumatic stress disorder (PTSD) is extremely common in victims of abuse; symptoms may persist for years. Complex PTSD in response to multiple severe traumas combines prolonged symptoms of PTSD with those of other psychological conditions. Anxiety disorders, various eating disorders, and repeated episodes of major depression are common sequelae. Survivors also suffer from difficulty with relationships and trust, long-standing shame and guilt, poor self-esteem, and anger. Dissociative identity disorder is also a potential outcome when a young child experiences multiple severe abusive episodes for which adult memories may be elusive. In this condition, a more complex walling off of memories of abuse allows the person to develop more normally, free from memories of the abuse, although the boundaries between memories often start breaking down later in life. While controversial, the syndrome clearly exists and is more common than generally recognized.

Long Term Physical Health Effects of Sexual and Physical Violence Abuse survivors commonly experience multiple physical symptoms, especially abdominal and pelvic pain, genitourinary symptoms, fatigue, and headaches. Although medical conditions may explain some symptoms, many remain unexplained despite extensive evaluations. Whenever studied, women with unexplained symptoms often give a history of childhood and/or adulthood physical and sexual abuse, and women with sexual symptoms are likely to have a history of sexual abuse or assault. The Adverse Childhood Exposure Study found that adverse childhood experiences (including physical and sexual abuse and witnessing abuse of a parent) were strongly interrelated and that the number of categories of adverse exposures had a graded relationship to later adult diseases, including ischaemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. Diseases associated with four or more categories of exposures included ischaemic heart disease (OR=2.2), cancer (OR=1.9), stroke (OR=2.4), COPD (OR=3.9), diabetes (OR=1.6), fracture (OR=1.6), and hepatitis or jaundice (OR=2.4). 18

World Book of Family Medicine – European Edition 2015 Application of the strictly medical model to abuse survivors with chronic abdominal and/or pelvic pain, gastrointestinal symptoms, and dyspareunia may lead to multiple investigations and surgeries. Such painful, costly, and often revictimizing interventions can lead to complications, including adhesions and more chronic pain. Since previously abused women are more likely to be overweight, smoke, drink, use drugs, engage in risky sexual behaviours, and not get pap smears, they also are more prone to sexually transmitted disease, HIV/AIDS, unintended pregnancies, and various chronic diseases. Violence tends to perpetuate itself with repeating patterns in subsequent generations. Mothers with childhood or adult abuse experiences may be less able to protect their daughters from an abuser. Helping patients to break such patterns is challenging, and most physicians are not trained, skilled, or comfortable in identifying and assisting with survivors of abuse.

Identification and Management Victims of abuse seldom volunteer information about their abuse to clinicians but are generally willing to talk about their abuse histories when asked directly. Building trust before asking questions will enable patients to disclose abuse, even on a first visit, if asked in an appropriate manner. Using the “generalized other” technique can facilitate the inquiry, i.e., “Many of my patients have been threatened or hurt by others, as children or adults. Did anything like this ever happen to you?” If the patient answers yes, establishing safety for the patient and any children still vulnerable to the abuser is crucial. Another approach is to ask about abuse as part of the standard review of systems or as part of family history. Asking about a family history of alcohol and drug abuse can lead easily into questions about physical abuse of the patient and family members, followed by a question about sexual abuse. A subsequent question might be, “Since then has anyone ever tried to or made you have sex when you didn’t want to?” Another screening strategy is to ask the patient about to disrobe, “Is any part of this exam difficult for you?” - enabling disclosure before the vulnerability of being undressed. Clinicians should ask these questions when they have time to listen and respond appropriately. When adequate time is not immediately available, the clinician should schedule early follow-up, indicating the importance of prior abuse to the patient’s medical care. Empathy is critical. The clinician must state that the abuse was not the patient’s fault and should never have happened. Discussing abuse with a supportive clinician can be very therapeutic, but referral to counselling with a therapist skilled with abuse survivors is often the best approach when the patient is ready. In the meantime, the clinician should explore how the patient would feel most safe and comfortable receiving medical care. Clinicians need to consider the abuse history in the patient’s ongoing management, allowing survivors control over the timing and conduct of referrals and investigations. A complex, necessary task is helping survivors make the connection between the abuse and their physical and emotional problems, while not implying that symptoms are “all in their head.” Another task is acknowledging how ordinary health care can be frightening for abuse survivors; that exams and procedures considered part of routine care can easily re-traumatize them. Careful explanations and explicit consent for each aspect of disrobing and touch are critical. Because betrayal of trust is often a key source of trauma for abuse survivors, clinicians must continuously demonstrate honesty and trustworthiness for these clinical relationships to succeed. Giving patients control through attention to safety, and always allowing the patient accompaniment by a chosen safe person can facilitate the conduct of necessary and potentially empowering health care.

Take Home messages 

Abuse survivors commonly experience physical and psychological symptoms and syndromes.



The only way to find out if a patient has been abused is to ask.



Always affirm that the abuse was not the patient’s fault and should never have happened.



Recognize that ordinary health care can be frightening for abuse survivors.



Allow patients the maximum possible safety and control.

Original abstract http://www.woncaeurope.org/content/4376-health-consequences-emotional-physical-and-sexual-abuse

References 1.

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine. 1998; 14:245-258.

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World Book of Family Medicine – European Edition 2015 2. 3. 4. 5. 6. 7. 8.

Finkelhor D, Browne A. The Traumatic Impact of Child Sexual Abuse: A Conceptualization. American Journal of Orthopsychiatry 1985;55:530-41. Gallo-Silver L, Anderson CM, Romo J. Best clinical practices for male adult survivors of childhood sexual abuse: “Do no harm.” Perm J 2014 Summer;18(3):82-7. DOI: http://dx.doi.org/10.7812/TPP/14-009. Lacelle C, Hebert M, Lavoie F, Vitaro F, & Tremblay RE. (2012). Child sexual abuse and women’s sexual health: The contribution of CSA severity and exposure to multiple forms of childhood victimization. Journal of Child Sexual Abuse, 21, 571–592. Leeners B, Stiller R, Block E, Görres G, Imthurn B, Rath W. Effect of childhood sexual abuse on gynecologic care as an adult. Psychosomatics 2007 Sep-Oct;48(5):385-93. DOI: http://dx.doi.org/10.1176/appi.psy.48.5.385. Leserman, J, Li, Z, Drossman, DA, & Hu, YJB. (1998). Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: The impact on subsequent health care visits. Psychological Medicine, 28(2), 417-425. Raposo SM, Mackenzie CS, Henriksen CA, Afifi, TO. (2014). Time Does Not Heal All Wounds: Older Adults Who Experienced Childhood Adversities Have Higher Odds of Mood, Anxiety, and Personality Disorders. Am J Geriatr Psychiatry 22, 1241-1250. Sugaya L, Hasin, DS, Olfson M, Lin K-H, Grant BF, & Blanco C. (2012). Child Physical Abuse and Adult Mental Health: A National Study. Journal of Traumatic Stress. 25, 384–392.

© Isha Mehmood on Flickr 2009 AP Fellow. Location: Kathmandu, Nepal. Partner: IANSA/ SAP-Nepal

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World Book of Family Medicine – European Edition 2015 Zekeriya Akturk, MD [email protected]

5 – The Role of Family Medicine in Undergraduate Medical Education Zekeriya AKTÜRK 1, Turan SET 2, Kenan TAŞTAN 1, Nezih DAĞDEVİREN 3, Erkan Melih ŞAHİN 4, Cahit ÖZER 5 Affiliations - Formerly: Trakya University Faculty of Medicine, Department of FM Currently: 1 Atatürk University Faculty of Medicine, Department of FM 2 Karadeniz Technical University Faculty of Medicine, Department of FM 3 Trakya University Faculty of Medicine, Department of FM 4 Çanakkale 19 Mart University Faculty of Medicine, Department of FM 5 Mustafa Kemal University Faculty of Medicine, Department of FM

Introduction General practice / family medicine (GP/FM) is defined as “an academic and scientific discipline, with its own educational content, research, evidence base and clinical activity, and a clinical speciality orientated to primary care”. Although primary care is widely perceived to be the backbone of a rational health services system, medical education is widely based on disciplines other than family medicine. There is a discrepancy between the place of practice of medical graduates and the place where medical education is based: despite nearly 60% of the medical graduates being employed there, only less than 10% of the training happens in primary care facilities (Figure 1).

Figure 1: The mismatch in the balance between education and practice platforms.

Aim The aim of this paper is to describe the potential contribution of family medicine/general practice to undergraduate medical education (UME). The Past: During the early days of the discipline, it was discussed and suggested that family medicine should contribute to UME. However, it was not an easy task. There were even arguments that general practice is not 'scientific'. In Turkey, we had to wait more than another 20 years to see family medicine engaged in UME: in 2001 there were only seven actively lecturing family practice departments throughout 47 medical faculties (15%). That same year, Trakya University commenced UME of class one medical students with objectives such as “to teach the principles of primary healthcare, and basic procedures used in medical practice”. The Present: Over time, the contribution of family medicine to UME increased significantly. The discipline improved in all areas including service provision, management, research, and educational content. Today, almost 90% of European universities have GP/FM curriculum, the duration of clinical rotations ranging from 1 to 12 weeks. In Turkey 55/83 medical schools (66%) have a GP/FM curriculum. Some of the authors of this article joined a one-day workshop (http://www.ktu.edu.tr/dosyalar/17_02_15_769b1.pdf) where participants presented 21

World Book of Family Medicine – European Edition 2015 a literature review on the curricula of different schools. A summary of the suggested family medicine content was presented at the end of the workshop. As a result, the authors suggested family medicine should be taught during all three years of the pre-clinical phase in the six-year medical education as well as throughout the internship period (Table 1). Table 1. Topics suggested to teach for undergraduate medical education. Lecture name Basics of family medicine 1

Topics 1.

Clinical case presentation 1

2. 3.

Primary care medicine 1 Internationalization

4. 5.

Continuous professional development Time management

6. 7.

The effects of family on health The family life cycle

8. 9.

Genograms 1 Quality in health care

10. Basic quality improvement tools 11. Observation of hospital departments 12. Effective communication and body language 1 13. Definition and basic features of family medicine 14. Oral health 1 15. Humanities in medicine 16. Science philosophy Basics of family medicine 2

1.

Primary care medicine 2

2. 3.

Morbidity patterns in family medicine Genograms 2

4. 5.

Clinical case presentation 2 Contextual care

6. 7.

Comprehensive care Continuous care

8. 9.

Coordination of care Access to care

10. Effective communication and body language 2 11. Patient empowerment 12. Patient adherence 13. Medical malpractice 1 14. Home accidents 15. Professionalism 16. Behavioural change 1 17. First contact with the hospitalized patient Clinical family medicine

1. 2.

The biopsychosocial approach Consultation and referral

3. 4.

Effective communication and body language 3 Patient education 22

World Book of Family Medicine – European Edition 2015 5. 6.

Behavioural change 3 Adolescent health

7. 8.

Care of the elderly Simulation of common health problems

9. Health life styles counselling 1 10. Breaking bad news 11. Periodic health care 12. Periodic health care guidelines 13. Integrative medicine 1 14. Domestic violence 15. Pre-conceptional care 16. Pregnancy follow up in family practice 17. Healthy child follow up in family practice 18. Social responsibility projects 19. Care of the disabled person 20. Equity in health care 21. Patient interview and clinical examination Family practice application

1.

Medical records

2. 3.

Medical malpractice 2 Legal responsibilities of the health personnel

4. 5.

Forensic medicine services in family practice Sick leave in family practice

6. 7.

Low prevalence medicine Evidence based medicine

8. 9.

Coding in medicine Health life styles counselling 2

10. Integrative medicine 2 11. Management of co-morbid conditions 12. Polypharmacy 13. Medical literature review and guidelines 14. Laboratory use in family practice 15. Obesity follow up 16. Home visits and home care 17. Pregnancy follow up in family practice 18. Rational prescription 19. ECG reading in family practice 20. Direct chest X-rays in family practice 21. Oral health 2 22. Rural medicine 23. Family practice in extraordinary conditions and disaster medicine 24. Payment systems, insurance organizations and family practice 25. Community oriented family practice 26. Community based medical education 27. Duties of family physicians and family practice management 23

World Book of Family Medicine – European Edition 2015

Conclusion UME curriculum should be composed of topics predominantly related to primary and thus preventive health care services. However, it takes time for this fact to become a reality in its application within the UME. Over the last 40 years, there has been an extended gap in the discipline, and the recent developments and improvements are promising for the future. We believe that the WONCA working parties (http://www.globalfamilydoctor.com/groups.aspx) have contributed much to this success. Of special value are the activities of EURACT (www.euract.eu/) and EGPRN (www.egprn.org). Improvements are especially remarkable in the number of academic departments and staff. However, most of the contributions so far are via lecturing and interactive teaching inside the medical school facilities. Family medicine is a comparatively new medical speciality, but it is probably the oldest medical discipline. Hence, there is still a long way to go to involve clinical family practice in UME.

Take Home Messages 

Although most medical graduates practice in primary care, most of the training is based in hospital settings.



Even in the earliest documents of family medicine it was suggested that family medicine should be included in undergraduate medical education.



Today almost 90% of European universities have a GP / FM curriculum, the duration of clinical rotations ranging from 1-12 weeks.



Being a relatively new medical speciality, but probably the oldest medical discipline, family medicine should play a much greater part in undergraduate medical education.



We suggest family medicine play a part in all preclinical phases plus the internship period of the undergraduate medical education.

Original Abstract http://www.woncaeurope.org/content/63-role-family-practice-undergraduate-medical-education-experiences-trakya-university

References        

Allen J, Gay B, Crebolder H, Heyrman J, Svab I, Ram P. The European Definition of General Practice/Family Medicine. Barcelona: 2011. Starfield B. Is primary care essential? The Lancet. 1994;344(8930):1129-33. Aktürk Z, Dağdeviren N, Şahin EM, Özer C, editors. The Role Of Family Practice in Undergraduate Medical Education Experiences at Trakya University Medical Faculty. The 2001 Conference of the European Society of General Practice/Family Medicine; 2001; Tampere. Haviland JW. Implementing the Report of the Citizens Commission on Graduate Medical Education. Jama. 1969 Dec 8;210(10):1902-5. PubMed PMID: 4390945. Wright HJ. The contribution of general practice to undergraduate medical education. The Journal of the Royal College of General Practitioners. 1973 Aug;23(133):531-8. PubMed PMID: 4785745. Pubmed Central PMCID: 2157174. Brekke M, Carelli F, Zarbailov N, Javashvili G, Wilm S, Timonen M, et al. Undergraduate medical education in general practice/family medicine throughout Europe - a descriptive study. BMC medical education. 2013;13:157. PubMed PMID: 24289459. Pubmed Central PMCID: 4220558. Ünlüoğlu İ. Aile hekimliği disiplininde akademik yükselmeler ve doçentlik sınavları. Turkish Journal of Family Practice. 2013;17(3):137-41. Saultz J. Around the kitchen table. Family medicine. 2014 Jan;46(1):61-3. PubMed PMID: 24415512.

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World Book of Family Medicine – European Edition 2015 Jessica Watson, MBChB, DRCOG, DCH, DFSRH [email protected]

6 – Developing National Curricula for the Education and Training of Family Doctors Dr Jessica Watson, MBChB, DRCOG, DCH, DFSRH Academic Clinical Fellow School of Social and Community Medicine University of Bristol

As a GP trainee, I sometimes feel like an endangered species. Many of my peers from medical school have chosen hospital specialties, and non-medical friends find it hard to understand that I have chosen to be ‘just a GP’. Across Europe the proportion of doctors who train as specialists is rising (1). In the press General Practitioners face regular denigration, even from some specialist colleagues in hospital who have warned that ‘GPs are part of the NHS’s problem, not the solution’ (2). Yet the evidence suggests the opposite, that countries with strong primary care infrastructures have healthier populations, reduced health inequalities and greater cost-effectiveness (Starfield et al 2005). As a result, in 2008 Iona Health called for ‘A GP for every person in the world’ (3, 4). Yet before this can be achieved we need high quality general practice training schemes for every country in the world. Currently, even in Europe, general practice training varies considerably, and not all countries require a qualification in family medicine to work as a family doctor (4). In order to achieve improved training in family medicine for all, we should be looking at what already works, in countries with well-established training, using an evidencebased approach. WONCA provides an ideal forum for sharing innovation, knowledge and experience and at the annual Vasco da Gama preconference for new and future GPs, the topic of training is regularly discussed. Enthusiasts debate the relative merits and disadvantages of their countries’ training systems, highlighting areas for improvement. How can this shared learning and communal knowledge be captured, drawn out and used to benefit training throughout and beyond Europe? Various initiatives to compare training schemes in Europe have grown already from WONCA conferences. One initiative from EURACT was to develop a dynamic interactive database with information enabling comparisons between training schemes throughout Europe (2). Another approach which grew from the grassroot enthusiasm of trainees themselves was to create a motivation and satisfaction questionnaire, with the aim of exploring differences in motivation, satisfaction and workload across these very different vocational training schemes of Europe (5). Results showed high levels of satisfaction amongst family medicine trainees, and demonstrated that ‘positive’ motivators such as ‘challenging medically broad discipline’ are the main reasons for a career choice in family medicine. ‘Negative’ motivators such as ‘it remained after I ruled out other options’, ‘non availability of another specialty training’ and ‘did not get specialty training because of my grades’ were chosen by a minority, challenging some negative preconceptions of family medicine. Other more formal work arising from WONCA Europe has been highly influential in the development of family medicine training, such as the European Definition of Family Medicine (5), which describes the core competencies of family doctors. This 25

World Book of Family Medicine – European Edition 2015 has been used in negotiations with policymakers, educators, media and physicians, and formed the basis of national family practice curricula such as the UK Royal College of General Practitioners GP curriculum. Following on from this, more recently the WONCA Working Party on Education has produced WONCA global standards for postgraduate family medicine education (6), which will provide further thrust to drive quality improvement, new program development and recognition of family medicine training globally. However there is a balance and equipoise to be reached in the efforts to develop global standards and curricula, which need to be comprehensive enough to be relevant to all family doctors, without producing overly burdensome bureaucracy, which may hinder rather than help learning.

So what about Alternative Blue Sky Thinking, to Help the Development of Family Medicine Training? A thought experiment by Bernard Lietaer, a professor of economics, might suggest an option (8). The slogan would then be “to master your topic, you should teach it”. This means that everybody becomes a student as well as a teacher, an apprenticeship model running right through from graduation to retirement. At entry to family medicine specialty training (after 6+ years of basic medical education) every doctor would be given a sum of 1000 Sabers. For 1 Saber you can buy one hour of teaching or coaching by an elder colleague. The elder colleague can only get Sabers by teaching or coaching. After 3 years, the time of getting a Master degree, there is an appraisal by a senior assessor. If you can pass this appraisal and demonstrate that you have earned 1000 Saber, you are rewarded with time and money. You get a sabbatical leave of 3 months and the money you would normally get in those 3 months. An extra free month a year. Every year. If it seems hard to imagine how this could be implemented in countries with well established training then imagine how this sort of cascade effect might be beneficial in countries without well established family medicine training in place. In these countries an educational voucher system could set in motion a ‘learning multiplier’, providing educational opportunities despite a lack of available funds for formal teaching. The incentive of extra money and sabbaticals could help recruit and retain doctors in countries where family medicine can be seen as ‘low prestige’ and where there is often a significant ‘brain drain’ of qualified medical staff to other countries. Perhaps another way of thinking of it is that this is just a modified version of the cascade of learning which already happens each time a group of family doctors is brought together. As Margaret Mead famously said: Never underestimate the power of a few committed people to change the world. Indeed it is the only thing that ever has. This cascade of learning is hard to quantify but is something which is felt by family doctors each time they attend a WONCA or Vasco da Gama conference and meet with a group of committed and inspired family doctors who share their visions and goals. The ripples from this learning cascade back as ideas and innovations which are applied in the home countries of doctors all over Europe and beyond.

Take Home Messages 

In order to achieve a ‘GP for every person in the world’, we need family medicine training in every country in the world.



WONCA initiatives and collaborations can help drive development of national curricula.



Thought experiments can help us think outside the box.



Never underestimate the power of a few committed people.

Thank You The author wishes to thank Marco Roos, MD, academic clinical fellow at the Institute of Primary Care, University of Erlangen-Nuremberg, for his helpful suggestions on the article.

Original Abstract http://www.woncaeurope.org/content/3553-developing-national-curriculum-education-and-training-general-practitioners-united

References 26

World Book of Family Medicine – European Edition 2015 1. 2. 3. 4. 5. 6. 7. 8.

http://www.oecd-ilibrary.org/sites/health_glance-2013-en/03/02/index.html?contentType=&itemId=%2fcontent %2fchapter%2fhealth_glance-2013-24-en&mimeType=text%2fhtml&containerItemId=%2fcontent%2fbook %2fhealth_glance-2013-en&accessItemIds=%2fcontent%2fbook%2fhealth_glance-2013-en http://www.dailymail.co.uk/debate/article-2840252/Why-fear-GPs-NHS-s-problem-not-solution-surgeon-J-MEIRIONTHOMAS.html Starfield B, Shi L, Macinko J (2005). Contribution of Primary Care to Health Systems and Health. Milbank Quarterly; 83(3):457-502. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323039/ Heath I (2008). A general practitioner for every person in the world. BMJ; 336(7649):861.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323039/

Roos M, Watson JC, Wensing M & Peters-Klimm F (2014). Motivation for career choice and job satisfaction of GP trainees and newly qualified GPs across Europe: a seven countries cross-sectional survey. Education for Primary Care; 25: 202-210 http://www.woncaeurope.org/gp-definitions http://www.globalfamilydoctor.com/site/DefaultSite/filesystem/documents/Groups/Education/WONCA%20ME %20stds_edit%20for%20web_250714.pdf

http://www.lietaer.com/2010/01/the-saber/

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World Book of Family Medicine – European Edition 2015 Ignaas Devisch, PhD [email protected]

7 – Transient Illnesses Prof. Dr. Ignaas Devisch PhD Philosophy Professor in Philosophy of Medicine and Ethics Department of Primary Care and Family Medicine Ghent University, Belgium

Within the context of mental illnesses, Ian Hacking talks about ‘transient illnesses’, in that certain illnesses are typical for certain eras. (Hacking, 1998). By this, he does not state that an era determines its illnesses and therefore illnesses can be reduced to it; instead, he analyses why certain illnesses are more prevalent in certain eras than in others. ADHD, depression or bipolar disorder for instance, are diseases of our era. One can ask why we are limiting ourselves to mental illness? Obesity can also be described as a ‘transient illness’: it is a basic characteristic of our era, far more than it was before. Obesity is particularly a problem of contemporary society. Everywhere in city streets, you can drink coke or eat burgers and all of us are on a daily basis faced with a battery of advertisements, influences which can hardly be overestimated. Listen to the radio, watch television or walk on the streets: we all are bombarded with advertisements appealing us to enjoy our life via the consumption of food and beverages. (Minkler, 1999) The concept of transient illnesses opens up the forum for discussion on health and illness in today’s society. When discussing so called lifestyle diseases, many people consider individuals responsible for their health condition and people are even blamed for being sick (Wikler, 1987, 2002). Consequently, in many countries the pursuit of a healthy lifestyle has or is expected to become a criterion in the allocation of healthcare services. One of the crucial questions is what the consequences of this evolution would be for health care policy, for individuals and for society in general? If we consider individuals as autonomous and regard the way they live as largely a matter of their own free choice, it seems ‘logical’ to hold patients personally responsible for making (un)healthy life style choices when they try to obtain insurance or enter healthcare facilities. And if the individuals are unwilling to change their risky behaviour, could they then also be denied health care services? In short, the discussion about lifestyle also concerns responsibility and the amount of control that others should be allowed to exercise over an individual’s choice for a particular way of living. Critics of paternalism talk about control and tyranny, while defenders point out the importance of public interest. (Cosner Jr, 2008) The idea of transient illness has the potential to make a breakthrough in this debate and can be of help to general practitioners in facing patients with lifestyle diseases. It explains why people, at the very moment they make autonomous decisions, decide for things which are obviously analogous to the main characteristics of society, i.e. enjoyment of your personal life, putting your desires first, etc. Despite the fact we are often very aware of the possible consequences of our decisions for our health, a lot of us keep on making unhealthy choices – it is for instance hard to say we are not informed about the dangers of smoking and yet many people continue smoking (Devisch I & Dierckx, 2009).

Can we blame these people for making choices which result in consequences they have not opted for? Of course people are responsible, but societies do ‘produce’ illnesses as well. An old ‘Marxist’

28

World Book of Family Medicine – European Edition 2015 thesis would argue that the ‘system’ is responsible for everything. However, it is not that our choices are determined solely by social circumstances; it is not because our particular social context offers us fewer opportunities for physical activity that we are destined to live our life as obese. In as much as we should stop ‘blaming the patient’ because of his risk behaviour, we cannot simply shift the responsibility of the individual’s lifestyle to society. Therefore, we suggest the counter-intuitive thesis: there are aspects of our behaviour for which no one is responsible. By this we mean that many of our choices are developed as a strategy for living our lives or – similarly to what Carl Elliott writes about in his ‘A Philosophical Disease. Bioethics, Culture and Identity’ – “the result of cultural factors beyond our reach”(Elliott, 1999). As long as lifestyle is considered to be based solely on independent, conscious and deliberate choices, be they taken individually or collectively, we will never solve the question of why people are ‘choosing’ one thing or refusing another. Beginning with the idea of transient illness, people should be viewed in a societal context which makes their individual freedom and choices a relative and not an absolute matter. To be free is more a question of ‘are the terms of the choice’ fair? If the available alternatives to a healthy choice are less attractive than they can/should be, maybe the terms of the unhealthy choice are unfair. For example, working in a coal mine; you know it is risky, but sometimes, there is no alternative. These people need to be protected, not punished.

Take Home Message 

General practitioners should be fully aware of the idea of transient illnesses and make use of it in supporting patients struggling with lifestyle diseases. Rather than blaming the victim, people deserve support and understanding for the context in which they live and the choices stemming from it.

Original Abstract http://www.woncaeurope.org/content/36-theory-general-practice-concepts-illness-and-paradigm-general-practice

References       

Cosner Jr, L. (2008). Lifestyle is an issue. Modern Healthcare, 38(13), 21-21. Devisch I, & Dierckx, K. (2009). On idiocy or the plea for an Aristotelian health policy. Public Health, doi:10.1016/j.puhe.2009.04.009. Elliott, C. (1999). A philosophical disease: bioethics, culture and identity. London and New York: Routledge. Hacking, I. (1998). Mad Travellers: Reflections on the Reality of Transient Mental Illnesses. London: Free Association Books. Minkler, M. (1999). Personal Responsibility for Health? A Review of the Arguments and the Evidence at Century's End. Health Education & Behavior, 26(1), 121-141. Wikler, D. (1987). Who should be blamed for being sick? Health Education Quarterly, 14(1), 11-25. Wikler, D. (2002). Personal and Social Responsibility for Health. Ethics & International Affairs, 16(2), 47-55. doi: 10.1111/j.1747-7093.2002.tb00396.x

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World Book of Family Medicine – European Edition 2015 Odd J Kvamme, MD, PhD [email protected]

8 – Cooperation Across the Interface of Primary and Secondary Care Odd Kvamme MD, PhD Family doctor at Stord, Norway Co-authors Frede Olesen (Denmark), Marianne Samuelson (France)

Battle Zone Starting with a citation: “cultural interfaces are said to be like battle zones between the fronts of two armies facing each other: the situation creates uncertainty and fear, there are no rules, the one part trying to impose power to suppress the other part” (1). The primary secondary care interface is a clearly defined demarcation zone, and it has changed very little during the last 20 years. It is similar in different European countries (2). The patient seems too often to be caught in a “no mans-land” where they suffer from care fragmentation, not knowing what to do, what is to happen next, or who is coordinating (3). These days, the patient has become more like a consumer and customer, a tendency that is boosted by social media spreading messages about which services to demand. Competition is turning health care services into suppliers of health care in a market, and the family doctors find themselves often in an unexpected role to shop secondary care services for their patients, based on expectations or needs. Increase of cost in health care is by many attributed to inappropriate use of care at the interface (4).

Different Cultures Primary care and secondary care represent different cultures, and their interface represents the biggest hindrance for smooth care processes in modern health care systems (5). One important reason is fragmentation of secondary care as result of higher professional specialization, technology and focus on pathology, with the risk that persons are more often seen as organs or diagnoses than individuals. At the same time, family doctors struggle to keep a broad and patient-centred perspective in a jungle of new knowledge, patients’ increasing expectations and demands while coordinating complex diagnostics and treatment. Iona Heath has described the basis for these differences in an eloquent way: “In family medicine, patients stay and diseases come and go. In hospitals, diseases stay and patients come and go”. Working in separate medical realities may diminish understanding and even respect for the concerns of others. To be able to smooth patient journeys, professionals themselves must cross the interface to learn about the other side, share perspectives and seek mutual understanding and goals. However, little effort has still been devoted to bringing professional groups together to enable them to understand that their work is complementary with that of others in a single healthcare system. The probably best approach so far is a Danish model where family doctors act as advisers in hospitals (6). Improving interface problems has gradually caught the interest of professionals and leaders of health care (7). We all agree that seamless care is an important goal for 30

World Book of Family Medicine – European Edition 2015 quality improvement, but when it comes to broaden our perspectives and changing behaviour, we resist and regress.

Important Perspectives Four important perspectives of the quality of care at the primary/secondary care interface: 1. The system perspective: A system approach to better co-ordinated care implies that we should understand and discuss division of tasks across boundaries within the health care system. This can improve process-flow, reduce waste of resources and diminish patient risk. 2.

Perspective of medical quality: Patients must be given an interpretation of symptoms and findings within a holistic framework where biological, psychological and social aspects of health care are considered and weighted. They have the right to make choices for diagnostics and intervention (8). To achieve this, the professionals must cooperate. The alternative is obsolete: fragmented and uncoordinated care resulting in polyinvestigations, poly-interventions and poly-pharmacy. Patient perspective: Patients expect coordinated chains of investigation, treatment and follow up. It is important that professionals and leaders use patients’ experiences to improve quality of care on a systematic basis. Understanding patient perspective is an assumption for narrowing the “expectation gap”, where needs and expectations clash with offers.

3.

4.

Provider perspective: Modern health care systems are complex with multiprofessional providers. There needs to be capacity within the system to prevent and settle conflicts between specialities and professions. Competition should give way to mutual understanding of roles and skills.

Targets for Change Based on complexity and perspectives, in 2001 the EQuiP listed ten targets for quality improvement of the interface (2). They are still valid. 

Develop leadership with a defined responsibility for improving the interface



Develop a shared care approach for patients treated in both primary and secondary care



Create consensus on explicit task division and job sharing



Develop guidelines that describe quality problems at the interface and seek solutions to such problems



Develop an interface that contains the patient perspective



Develop systems for appropriate information exchange to and from family medicine care



Reinforce interface improvement through education



Facilitate team building across the interface



Establish quality monitoring systems at the interface



Establish a broad understanding of the need for cost effectiveness at the interface

The work required in different countries must be based on national needs, resources and priorities. Improvement of leadership is probably the most important target. So is bringing family doctors and specialists together to develop personal and group relations and understanding. Bridging the expectation gap by informing and empowering patients will also be a strong drive to improve communication and cooperation across the interface. The ten targets can help redesign health care systems in order to deliver care that is perceived by patients as seamless. Working towards these targets can help leaders to make care systems work as a whole. In Norwegian hospitals there is a new trend assigning family doctors with public health experience to the leadership. The Danish model for family doctors as advisers in hospitals is a multi-potential method to promote cooperation (6). Studies of patients’ expectations and experiences can help professionals to act in accordance with guidelines for medical practice and cooperation. Improving care across the interface is a continuous process that must be based on principles for quality improvement. Shared perspectives and common goals can lead to behavioural and system change. Both carrots and sticks are needed to accomplish the task.

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Take Home Messages 

The interface primary/secondary care represents major obstacles for seamless care



The culture gap between primary and secondary care needs closing by sharing perspectives and goals



The subject must be addressed both by leaders, family doctors and specialists



Improving care across the interface must be based on principles for quality improvement



Patient experiences must be monitored and listened to

Original Abstract http://www.woncaeurope.org/content/24-interface-between-primary-and-secondary-care-continuity-shared-care

References 1. 2. 3. 4. 5. 6. 7. 8.

Bateson, G. Cultural contacts and Schismogenesis. I: Steps to an ecology of mind. London: Intertextbooks, 1972. Kvamme OJ, Olesen F, Samuelsson M. Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP). Qual Health Care 2001;10:33-9. Preston C, Cheater F, Baker R et al. Left in limbo: patients’ views on care processes across the primary/secondary interface. Qual Health Care 1999; 8:16-21. Improving care at the primary-secondary care interface: a difficult but essential task. Szecsenyi J. Qual Health Care. 1996;5:191-2. Kvamme OJ, Eliasson G, Jensen Poul B. Co-operation of care and learning across the interface between primary and secondary care. Scand J Prim Health Care. 1998; 16:131-4. Olesen F. General practitioners as advisors in hospitals. Qual Health Care 1998;7: 42-7 Grimshaw JM, Winkens RA, Shirran L, Cunningham C, Mayhew A, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005471. Berendsen AJ, de Jong GM, Schuling J, Bosveld HE, de Waal MW, Mitchell GK, van der Meer K, Meyboom-de Jong B. Patient's need for choice and information across the interface between primary and secondary care: a survey. Int J Integr Care. 2004;4:18.

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World Book of Family Medicine – European Edition 2015 Joachim P Sturmberg, MD, PhD [email protected]

9 – Complexity and Primary Care Joachim P Sturmberg MD, PhD A/Prof of General Practice, Newcastle University, Newcastle - Australia

Complexity comes from the Latin word complexus; com- “together” and plectere “to weave” or “braid”. By studying complexity, we aim to understand how things are connected, and how these interactions relate to one another. Complexity also entails a particular way of thinking, a change in world view, away from understanding the whole based on knowledge of its individual parts towards an appreciation that the parts exhibit different properties to those they display in the context of the whole. In complex science lingo; the whole is different and more than the sum of its parts (Fig. 1). Furthermore, the behaviour of system components varies depending on context; changing context may result in “unexpected” changes in the component’s and therefore the system’s behaviour [1].

Fig 1: Gauss and Pareto distributions, the basis that define the key differences between simple and complex world views. Note: the long-tail frequency distribution and its log-log equivalent are superimposed – modified from West. (2010) Homeostasis and Gauss Statistics: barriers to understanding natural variability. J Eval Clin Pract. 16(3):403–8) Complex systems consist of many different parts (agents) contained within a boundary separating it from other systems. Hence every system is part of a suprasystem and itself contains many sub-systems. Systems have permeable boundaries, providing output and receiving input from their external environment. A system’s agents are interconnected, interacting in multiple ways; each agent influencing others and in turn being influenced by

33

World Book of Family Medicine – European Edition 2015 their responses resulting in feedback which gives the system its unique non-linear behaviour. Most importantly, systems behaviour is non-deterministic, its behaviour will change in major ways with even the smallest change in its agents’ initial condition (or starting value) (Fig. 2) [2].

Fig 2: Complex systems and their core characteristics: the boundaries of a system and its supra- and sub-system context (top left), interconnectedness of agents (top right) resulting in feedback (bottom left), and the impact of initial condition (or starting value) on its behaviour (bottom right) Primary care exhibits all the characteristics of a complex (adaptive) system [3, 4]. Structurally, primary care is part of the wider healthcare system; its agents are members of the community and various health professions. Each agent within the primary care system consists of members of its respective craft group. Important agents outside the primary care system, like teachers, public services, employers etc., receive outputs and provide inputs to the primary care system. Dependent on the size and the number of agents involved, their interactions lead to unique behaviours, and the behaviour can vary markedly between various local settings, no more so than in light of the socio-economic conditions of the local area. How can you implement complexity thinking into problem solving in primary care? The following examples illustrate and explain some system and system-dynamic approaches for everyday practice. Most frequency distributions in nature show long tail or non-linear (log-log normal, power law, 80:20 split or Pareto) distributions. Health in the community has long been known to be distributed that way – most people are healthy most of the time, and most people with a health concern have conditions amenable to primary care treatments. Only 3.2% of the community require secondary and 0.8% tertiary care. Many physiological parameters, like blood pressure, cholesterol and BMI, show non-linear distributions. These distributions highlight the gross over-classification of patients as abnormal, not only mathematically but also pragmatically. Physiological variables operate within a homoeostatic range, i.e. they show threshold behaviour in regards to outcomes, like blood pressure in relation to morbidity or income to life-expectancy [5]. Multiple cause diagrams provide a means to fully appreciate the dynamic changes underpinning a person’s illness trajectory as illustrated by John, a patient with multiple problems known by any primary care provider anywhere in the world (Fig. 3). Changing disease-specific parameters more often than not result from influences of factors distant to the disease processes (the “real reason” for the deterioration of disease markers). Failing to see the whole picture easily results in unnecessary and/or inappropriate management, overlooks the patient’s real needs and results in less than the best possible health outcomes [6]. In primary care, multiple agents interact with people with usually multiple, less-defined illnesses that typically exhibit more unpredictable dynamics and outcomes, i.e. they deal with greater complexity. In situations of high complexity health professionals have to rely on improvisation, using multiple different approaches to adapt to seemingly “similar problems” in a patient at different points in time, or different patients or patients in different environments. Katerndahl demonstrated that primary care physicians deal with far greater complexity and greater uncertainty compared to focused physicians like cardiologists and psychiatrists. Not surprisingly working in a more complex environment creates greater stress and is associated with a higher error rate, both being outcomes of the system’s dynamics [7].

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Fig 3: Multiple cause diagram of patient with multimorbidity – the multiple cause diagram shows that John is part of at least three subsystems. John’s central problem is stress. His retrenchment, marital problems and worries about his sons all increase his stress and stress response. The causal loops are self explanatory from their physiological and pharmacotherapeutic perspective. Of note are the synergistic effects caused by the input of multiple variables, e.g. increased alcohol consumption and smoking both cause a decrease in mucosal protection which in turn increase ulcer/reflux symptoms and stress (Sturmberg. (2007) Systems and complexity thinking in general practice. Part 1 clinical application. Aust Fam Physician 36(3):170-173) The whole health system can be understood by the healthcare vortex metaphor which visualises the interconnectedness of all agents at the various organisational levels of health care. The metaphor highlights a core feature of complex adaptive systems; its interconnected function depends on sharing a common value or focus that in turn generates common simple rules to operationalise each agent’s behaviour. This model creates a space in which primary care can lead the discourse for healthcare reform that meets all the various needs for which people require the help of a health professionals (Fig 4) [4]. To succeed in primary care we have to acknowledge and embrace its underlying complexities and uncertainties. There are now a variety of accessible tools that can help us to better cope, learn and act. Using these tools is of paramount importance as they help to overcome our brain’s limited capacity to simultaneously process more than a few things (on average 7 ± 2) at a time, to easily detect connections between seemingly unconnected objects or facts, and to easily anticipate – especially nonlinear – behaviours more than a step or two ahead. Acknowledging our limitations in dealing with complexity can easily be compensated for by adopting the science’s foundations and tools; it will make us better problem solvers and decision makers [8]. Systems and complexity-orientated primary care offers patient-centred, individualised, health-focused healthcare that integrates the best solutions with regard to each person’s needs.

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Fig 4: The health vortex as a metaphor for the health system. Note the changes between certainty and complexity at the various levels within the health vortex.

Take Home Messages 

Complexity and uncertainty are core characteristics of primary care



Variables in “living systems” have non-linear (long-tail) distributions



Small changes in a single system variable can result in largely divergent system behaviours



Applying system tools helps to understand complex problems and guides the development of solutions



Simple rules arising from a shared common focus (value) provide the operating principle for all system agents

Original Abstract http://www.woncaeurope.org/content/56-complexity-and-primary-care

References 1. 2. 3. 4. 5. 6. 7. 8.

West BJ. Homeostasis and Gauss Statistics: barriers to understanding natural variability. J Eval Clin Pract. 2010;16(3):403– 8. Sturmberg JP, Martin CM. Handbook of Systems and Complexity in Health. New York: Springer; 2013. Sturmberg JP, O’Halloran DM, Martin CM. People at the centre of complex adaptive health systems reform. Med J Aust. 2010;193(8):474-8. Sturmberg JP, O'Halloran DM, Martin CM. Health Care Reform – The Need for a Complex Adaptive Systems Approach. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer; 2013. p. 827-53. Sturmberg JP, West BJ. Fractals in Physiology & Medicine. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer; 2013. Sturmberg JP. Systems and complexity thinking in general practice. Part 1 - clinical application. Aust Fam Physician. 2007;36(3):170-3. Katerndahl D, Parchman M, Wood R. Trends in the perceived complexity of primary health care: a secondary analysis. J Eval Clin Pract. 2010;16(5):1002-8. Dörner D. The Logic of Failure: recognizing and avoiding error in complex situations. New York: Metropolitan Books; 1996.

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World Book of Family Medicine – European Edition 2015 Siggy Rausch, MD [email protected]

10 – Motivational Interviewing in Family Medicine Siggy Rausch, MD Lecturer in Medicine University of Luxembourg, co-responsible for the organization of the Specific Training in General Medicine at Uni Luxembourg Lecturer in Medicine, Free University of Brussels (ULB) Member SSLMG (Scientific Society of General Medicine in Luxembourg)

“People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the minds of others.” Blaise Pascal When we, as family doctors, have to deal with physical ailments, we can offer explanations, good advice and healing treatments and, for the most part, there is a successful outcome for the patients. However, we are often faced with more challenging situations. When the issue relates to dangerous behaviour, such as smoking, alcohol abuse, drug abuse, excessive eating, lack of exercise, not adhering to prescribed treatments etc., we can be faced with a resistance to our best efforts at advice and treatment - where people continue to behave in self-defeating ways. In this situation, our helper role often proves ineffective: when we have given our best advice and stressed the importance of a change in behaviour, we are often left with the frustrating feeling of failure. Patients can react in unexpected ways. They sometimes resist our advice and, indeed, argue against it. They can get angry and defensive, thus provoking feelings of frustration in us. We may even think that he/she “has bad will or is too silly to follow our advice”. Motivational Interviewing (MI) was developed more than 30 years ago in the setting of alcohol dependence treatments. The approach to counselling advocates is particularly relevant in the above context (2). We doctors are trained to use what can be called the “Deficit Model” which implies that “my patient lacks something (insight, information, understanding) and my role is to give him what is missing. The word “docere (to teach)” which is the origin of “doctor” is the basis for this “deficit model”. In MI the approach is different and has to do with “E-ducere (to draw out)”. That means search and draw out what is already present which includes what the patient himself may know. With this approach, the doctor and the patient search together, for a solution. Instead of focusing on the failings of the patient (which may be important) we focus on his/her resources, possibilities, wishes, hopes, strengths and capacity to change.

Our efforts are twofold 

First, we encourage our patient to find arguments himself/herself, in favour of change.



Second, we listen carefully to every element of “change talk” the patient expresses, we support his/her ideas for change and help develop them into a strategy that he/she will be able to apply. Ambivalence about the problematic behaviour is the starting point for MI intervention. Possibly, our first goal is to reveal this ambivalence. To get to understand the specific nature of our 37

World Book of Family Medicine – European Edition 2015 patient's ambivalence, we need to avoid a directional and “expert” driven style. Instead, we should adopt an empathetic, reflective, listening style in order to communicate understanding of the patient’s inner world of conflicts. Reflective listening involves the following skills: 

Using Open Questions.



Making reflections aloud to show empathy and to test whether we have understood what the patient meant.



Affirming the strengths and qualities of the patient.



Summarising to check that both doctor and patient have the same understanding of what has been said and/or agreed.

Studies show that these skills are easy to understand, but difficult to use in a fluid and easy manner during a consultation. Like the game of tennis - easy to understand, but not so easy to master well! A lot of training and supervision is necessary (3). The Spirit of MI, is defined essentially by our will to collaborate with the patient and activate his/her own expertise. It means Unconditional Acceptance, Empathetic Reflection and support for the patient's Autonomy and this can be summed up as: “I’m here to help but it’s up to you to decide where to go and what to do”. An important element of Acceptance is affirming the qualities and strengths we can observe in our patient. This is linked to Compassion which is another important element of the spirit of MI and implies “I want the best for my patient”. MI usually starts with Engaging: “Do I understand this person’s perspective and concerns? “How comfortable is this person in talking to me?” This is followed by Focusing which is to look for the “goals for change” and questions “Are we working together with a common purpose?” “Does this feel more like dancing or wrestling?” Next comes Evocation which means: “What are this person’s own reasons for change? Is his/her reluctance more about confidence or the importance of change? What change talk am I hearing? Am I steering too far or too fast in a particular direction? Is the reflex “to be right” making me the one to be arguing for change?” The last element is Planning which takes in: “What would be a reasonable next step toward change? What would help this person to move forward? Am I retaining a sense of quiet curiosity about what will work best for this person?” (1 p.311). MI is described as a style of being with people, an integration of particular skills to foster motivation for change. It is essentially a collaborative partnership that honours the other’s autonomy, seeking to understand the patient’s internal frame of reference. Compassion is added to the spirit of MI precisely to emphasise that MI is to be used to promote the patient’s welfare and best interests, not one’s own. There are currently a lot of studies showing the efficacy of MI (4, 5, 6,7,8). The most powerful change catalysts operating in MI include empathic listening, the capacity to strengthen change talk, and the therapists ability to refrain from counter therapeutic responses (1 - p.386). One last word: there is a benefit for the family doctor himself in MI. My experience in adopting this style of interaction with my patients is that, not only is there a greater degree of satisfaction in the doctor/patient relationship, but it is also an effective preventative measure for ‘burnout’.

Take Home Messages 

When patients resist the doctor’s advice, it’s time for MI



MI gets much better results than blaming or criticizing



When patients hesitate to consider behaviour change, it’s time for MI.

Original abstract http://www.woncaeurope.org/content/ws216-applications-motivational-interviewing-hypertension-treatment

References 1.

Motivational Interviewing. William R. Miller, Stephen Rollnick, Third edition 2013 New York Guilford Press

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World Book of Family Medicine – European Edition 2015 2. 3. 4. 5. 6. 7. 8.

Health Behavior Change. S. Rollnick, P.G.Mason, C.C.Butler Churchill Livingstone 1999 Building Motivational Interviewing Skills. D.B. Rosengren New York Guilford Press 2009 see the ref. in (1) p.435 - 470 especially: Bien,Miller 1993; Brown, Miller 1993; Bohart, Tellman 1999; Hubble &al 1999, Miller & al 1993, Project MATCH research group 1998 Hettema & al 2005, Hubble, Duncan, Miller 1999, Sanders L.2011, White, Miller 2007) D’Amico EJ et al, Group Motivational Interviewing for Adolescents. Change Talk and Alcohol and Marijuana Outcomes J Consult Clin Psychol 2014 Nov 3 Vesely JM et al.: Obesity: Dietary and Lifestyle Management FP Essent. 2014 Oct; 425: 11-5 Vasilaki EI et al: The Efficacy of Motivational Interviewing as a Brief Intervention for Excessive Drinking: a Meta-analytic Review Alcool Alcool 2006 May-Jun; 41 (3) ; 328-35 Keeley R.D. et al Training to Use Motivational Interviewing Techniques for Depression. J Am Board of Family Med 2014; 27: 621-636

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World Book of Family Medicine – European Edition 2015 Adrian Rohrbasser, MD, MSc EBHC [email protected]

11 – Quality Circles Adrian Rohrbasser, MD, MSc EBHC Department of Primary Care Health Sciences University of Oxford Santémed Healthcare Centres Switzerland Co Author: Edith Andres, Dipl.-Psych Institute for Applied Quality Improvement and Research in Health Care GmbH

The Phenomenon Ongoing quality improvement (QI) is fundamental to modern family medicine; it is about providing person-centred, safe and effective care, and efficient use of current resources in a fast-changing environment. There are diverse methods, tools and approaches to QI and structured small group work has been shown to contribute to an individual's increase and use of knowledge. The terms peer review group (PRG), quality circle (QC), CME/CPD (continuous medical education/continuous professional development) group, practice-based small group work (PSGW) and small group work (SGW) are used interchangeably in different European countries. QCs are groups of 6 to 12 professionals usually working in general practice, who meet regularly to consider their standard practice. QCs select the issues they want to deal with and decide on their data-gathering method and on ways of finding solutions to their problems. Practitioner-participation, certain topics and thematic frameworks may be mandatory for accreditations or for reimbursement by health insurance companies. The groups provide a social context for reflective practice and allow the dissemination of knowledge to the work practices of the participants (1). QCs consist of more than one educational step and are best described as a multifaceted intervention which uses various predisposing, enabling and reinforcing methods (2). They use educational material which is discussed in a workshop-like atmosphere, contact with local knowledge experts, audit and feedback with or without outreach visits, facilitation and local consensus processes. The groups are led through the circle of quality by facilitators who seek to keep the members focused on the issue without controlling them, respecting the contribution of each individual and taking into consideration the group dynamics. Rhetoric and didactic techniques such as debate, consensus discussion, brainstorming, reflective thinking, self-observation and role play, among other practice, appear to keep QCs active.

Origins of the Approach QCs are based on two concepts: the framework of Knowledge-To-Action-Cycle (KTA) and the social context the group provides for its function. In 1924, Walter Shewart created the first table depicting a circle for continuous control of the process and QI. The US statistician Deming enhanced this and introduced the Plan Do Check Act (PDCA) cycle as a method of QI. QI spread from manufacturing to service industries and then to medical service providers. Donabedian introduced the basic aspects of quality and QI in health care using the same terms as the manufacturing industry. This concept was first implemented in in-patient settings and secondary-care clinics in the Netherlands, where Problem Based Learning (PBL) first influenced the health care sector. In 1979, PBL was implemented experimentally in Nijmegen, in the Netherlands, where small groups of family physicians met voluntarily on a regular basis, using their peers to 40

World Book of Family Medicine – European Edition 2015 continuously and autonomously improve their knowledge. Gradually, the learning cycle transformed into a cycle of QI as the focus changed from knowledge gain to QI and implementation of knowledge according to the KTA framework (Fig 1)(3). PBL added didactic techniques and industrial QCs added communication skills and knowledge about group dynamics to these small primary health care groups. QCs spread rapidly to many European countries. A parallel development could be observed at Mc Master University in Canada in the Eighties.

Fig 1: KTA Framework

Significance of the Phenomenon and its Development According to a survey performed by the European Society of Quality and Safety in Family Medicine (EQUiP) presented at the WONCA Conference in 2000, of the 26 European countries which participated, QCs had been established in Austria, Belgium, Denmark, Germany, Ireland, the Netherlands, Norway, Sweden, Switzerland and the UK. The main objectives of QCs in primary health care being QI, CPD and CME (4). Numerous Dutch, German and Scandinavian studies conducted in the following years suggest that QCs improve both individual and group performance in terms of costs, ordering of tests, prescription habits and adherence to clinical practice guidelines, thus resulting in better patient outcomes, measured in changes in performance indicators (5). As the QC programme uses several, though varying sequential interventions, it is tempting to judge the programmes according to the results each component generates. Several systematic reviews (SR) of high quality show that elements of QCs have a positive impact on behaviour (6, 7). In the Netherlands and Ireland, QCs have become inherent in QI where family physicians are supported by their colleges. In Germany, they are often mandatory as part of integrated or selective contracts in health care. Overall, approximately 50% of all family physicians participate regularly in QCs. In Switzerland, currently, 80% of all primary health care physicians who answered surveys, regularly attend QCs. QCs have developed rapidly in Scotland and England and over 25% of all family physicians in Scotland regularly meet in groups. There are no current data for other European countries about how common QCs are and what features they have. However, literature reviews and contact with European key stakeholders suggest that QCs also play an important role in Austria, Belgium, Denmark, France and Sweden. 41

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Future Prospects QCs are assumed to work because they bring people together to identify key issues concerning the quality of health care and they involve people in exploring solutions where there is a need for improvement. However, understanding of the QC components that act independently and interdependently to optimize the programme has to be improved. The influence of the context should be taken into account and studied since it affects both participants and their motivation. Basically, it is about unpacking the black box to see what variations of QCs work for whom and under what contextual features, by looking at the numerous projects that are being undertaken (8). An EQUiP meeting on this subject is planned in Spring 2015 and an updated survey on QCs in European countries will be conducted to discover how common they are, what contextual features they display and to identify optimal conditions for their success.

Take Home Messages 

Quality Circles are commonly used in primary health care in Europe to consider and improve standard practice over time.



They represent a complex social intervention that occurs within the fast-changing system of primary health care.



Quality Circles work according to the Knowledge-To-Action Framework



Numerous controlled trials, reviews and studies have shown small but positive effects on behaviour change.

Original Abstract http://www.woncaeurope.org/content/20-s-quality-circles

References 1. 2. 3. 4. 5. 6. 7. 8.

Grol R: Quality improvement by peer review in primary care: a practical guide. Qual Health Care 1994, 3(3):147-152. Davis DA, Thomson MA, Oxman AD, Haynes RB: Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995, 274(9):700-705. Straus SE, Holroyd-Leduc J: Knowledge-to-action cycle. Evidence Based Medicine 2008, 13(4):98-100. Beyer M, Gerlach FM, Flies U, Grol R, Krol Z, Munck A, Olesen F, O'Riordan M, Seuntjens L, Szecsenyi J: The development of quality circles/peer review groups as a method of quality improvement in Europe. Results of a survey in 26 European countries. Fam Pract 2003, 20(4):443-451. Zaher E, Ratnapalan S: Practice-based small group learning programs: systematic review. Can Fam Physician 2012, 58(6):637-642, e310-636. Baskerville NB, Liddy C, Hogg W: Systematic Review and Meta-Analysis of Practice Facilitation Within Primary Care Settings. The Annals of Family Medicine 2012, 10(1):63-74. Ivers N, Jamtvedt G, Flottorp S, Young Jane M, Odgaard-Jensen J, French Simon D, O'Brien Mary A, Johansen M, Grimshaw J, Oxman Andrew D: Audit and feedback: effects on professional practice and healthcare outcomes. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2012. Rohrbasser A, Mickan S, Harris J: Exploring why quality circles work in primary health care: a realist review protocol. Systematic Reviews 2013, 2(1):110.

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World Book of Family Medicine – European Edition 2015 Buis, P.A.J., MD, PhD [email protected]

12 – Pathology and Minor Surgery in Primary Care Buis, P.A.J., MD, PhD Former: Department of Pathology University Medical Centre Utrecht Cancer Center Utrecht The Netherlands Current: Gezondheidcentrum Harderwijk, Harderwijk, The Netherlands

Since last century, family doctors have played a varying role in the management of skin lesions. While family doctors traditionally played an important role in handling skin lesions, this changed in the second half of last century when minor surgery performed by family doctors declined as a result of limited funding and the growing wish of patients to be treated by specialists. The increasing costs of this led to the insight that minor surgery primarily belongs in family medicine, and financial incentives were created for family doctors to perform more minor surgery. Since then, the role of family doctors in the management of skin lesions has gradually increased, illustrated by a significant increase in the volume of minor surgery performed in primary care in the UK. This largely involves skin lesions that may be malignant, and thus there has been discussion about the appropriateness of clinical management decisions in family medicine with several issues of concern: 

The quality of the clinical diagnosis by family doctors



The need for histological confirmation of the clinical diagnosis



The cost-effectiveness of histological confirmation



The technical quality of the surgical procedures performed by family doctors



The cost-effectiveness of minor surgery in family medicine

Pathology applications in Family Medicine can concern cytological or histological investigations. Histology is also of great importance in Family Medicine, in terms of skin excisions, biopsies and curettings. Skin diseases are a major part of the workload of the family doctor, reflecting about 15% of daily consultations. Skin cancer incidence rates have increased steadily, leading to a growing demand for healthcare services to inspect suspected lesions and treat patients. In The Netherlands, lifetime risk of skin cancer is 1:6 and of melanoma is 1:50. In many countries, including The Netherlands, family doctors are the portal to healthcare and therefore play an important role in handling skin lesions. Nevertheless, the role of family doctors in these matters is not without controversy. Family doctors are criticized because of their lack of diagnostic accuracy and quality of their surgical technique. To have clear insight into this process it is important to know how family doctors handle skin lesions in daily practice and to know what the role of histopathological investigation is following skin excisions. We evaluated the yield of histopathological investigation of a large group of 5105 skin excisions performed by family doctors and sent to a family doctors' pathology lab in Utrecht (Saltro), with special emphasis on discrepancies between clinical and pathology diagnoses of malignancy. The total yield of (pre-)malignancies in this large group of skin excisions was about 5%. These (pre-) malignancies were often serious and unexpected. Table 1. Comparison of clinical and final histological diagnosis in 5105 skin biopsies and excisions by family doctors. 43

World Book of Family Medicine – European Edition 2015 Final histological diagnosis Clinical diagnosis

benign

premalignant

malignant

unknown

total

4302 (96.6%)

34 (0.8%)

100 (2.2%)

16 (0.4%)

4452

12 (42.9%)

13 (46.4%)

3 (10.7%)

malignant

66 (50%)

11 (8.3%)

54 (40.9%)

1 (0.8%)

132

unknown

441 (89.5%)

12 (2.4%)

35 (7.1%)

5 (1%)

493

4821

70

192

22

5105

benign premalignant

total

28

In the group of benign clinical diagnoses we found 3% (pre-) malignancies. The malignancies occurred over the whole spectrum of clinical diagnoses including epidermal/trichilemmal cyst, seborrhoeic keratosis, naevocellular nevus, verrucous wart and fibroma. This indicates that clinical assessment of skin lesions by family doctors may be insufficiently reliable in allowing some skin excisions to be exempt from histopathological investigation, and that all skin excisions by family doctors deserve to be routinely investigated by histopathology in order not to miss serious malignancies. We compared melanomas excised by family doctors with those excised by dermatologists and surgeons in an academic practice to identify the nature of melanomas missed by family doctors, which may be translated into better clinical practice for family doctors. Of the family doctor melanomas, 64% were clinically considered to be a benign nevus in contrast with 38% of academic melanomas. This does not necessarily mean that family doctors do worse in diagnosing melanoma, since family doctors will usually refer patients with highly suspicious lesions anyway, and the low index of suspicion lesions will be treated by the family doctors (pre-selection bias). A low index of suspicion will usually lead to a narrow primary excision with a higher risk of an incomplete excision. The general consensus is to refer pigmented lesions with a high index of suspicion to a dermatologist or surgeon for a slightly wider local excision followed by reexcision and sentinel node biopsy if indicated. In a study exploring whether the “ugly ducking” (UD) sign is sensitive for melanoma detection it was concluded that melanomas are generally apparent as UDs. It is a common observation that, in a given individual, all the nevi tend to show a similar pattern. A nevus that stands out, the ugly duckling, is suspicious. Translating this knowledge to Family Medicine it seems very important to let patients undress when assessing pigmented skin lesions in order to investigate the overall pattern of the skin moles and to detect the “ugly duckling” if present. The safest approach to skin lesions is to excise them all and submit them for histopathology. However, this would lead to unwanted cosmetic side effects and low cost-effectiveness. Better diagnostic strategies could help family doctors to discriminate between benign lesions that can be left alone and high index of suspicion lesions that need to be excised properly. Dermatoscopy is widespread in secondary care and has been suggested as a tool to improve the diagnostic accuracy and therapeutic management by family doctors as well.

Take Home Messages 

The total yield of (pre-)malignancies in skin excisions submitted for pathology is between 5% and 10%, most of them unexpected, including serious malignancies.



Unexpected malignancies in skin excisions performed by family doctors occur across all clinical diagnosis categories, and about 2% of clinically 100% benign lesions are malignant.



Lowering the number of unnecessary excisions is a more fruitful approach to cost-saving than omitting histopathology of excised lesions.



It seems very important to let patients undress when they present with a pigmented skin lesions to investigate the overall pattern of the skin and to detect the “ugly duckling” if present.



Dermatoscopy may be a valuable addition for the diagnostic and management strategy of pigmented skin lesions by family doctors.

Original Abstract http://www.woncaeurope.org/content/27-pa-minor-surgery-primary-care-team

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World Book of Family Medicine – European Edition 2015

References: 1. 2. 3. 4. 5. 6.

O‘Cathain A, Brazier JE, Milner A, Fall M. The cost-effectiveness of minor surgery in general practice: a prospective comparison with hospital practice. Br J Gen Pract 1992;42:13-17. Lowy A, Brazier J,Fall M, Thomas K, Jones N, Williams B. Quality of minor surgery by general practitioners in 1990 and 1991. Br J Gen Pract 1994;44:364-365. Buis PAJ, Chorus R, Van Diest PJ. Value of histopathologic analysis of skin excisions by general practitioners. BJGP 2005;55:458-460. Buis PAJ, Verweij W, Van Diest PJ. Value of histopathologic analysis of subcutis excisions by general practitioners. BMC Family Practice 2007;8:5. Buis PAJ, van Kemenade F, Frijling BD, van Diest PJ. Skin melanomas excised by General Practitioners: more often unsuspected, of nodular type and less of often radically excised than those excised in an academic setting. Clinical and Experimental Dermatology 2011;2:125.doi:104172/2155-9554.1000125 Scope A, Dusza SW, Halpern AC. The “Ugly Duckling” sign. Agreement between observers. Arch Dermatol 2008;144:58-64.

© Pieter Buis

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World Book of Family Medicine – European Edition 2015 Mladenka Vrcic Keglevic, MD [email protected]

13 – Developing Research Capacities in General Practice: the Croatian Experience Mladenka Vrcic Keglevic, MD, PhD Professor, Department of Family Medicine, University of Zagreb School of Medicine, Zagreb, Croatia Co-authors Milica Katic, Đurđica Kašuba Lazić

Background Vocational training or specialist training (ST) in General Practice / Family Medicine (FM) in Croatia started in the school year 1960/61. It was prepared by the experienced working general practitioners (GP), supported by the academics, public health and clinical teachers from the Zagreb Medical School. The vision was not only based on the development of FM as the primary health care discipline, but also on the academic development of the discipline, which included the development of research capacities. Therefore, ST was organised along three pathways; as a postgraduate course, clinical rotations and the FM practical experience under the supervision of the trainers. A postgraduate course was equal to other postgraduate courses organised by Zagreb Medical School, leading to the obtaining firstly, a Master of Science degree followed by a doctoral degree. At the same time, ST trainees in FM have had the opportunity to proceed toward doctoral degrees and becoming a specialist in FM. Many GPs took advantage of this and obtained Master of Science degrees, and several of them doctoral degrees. A doctoral degree is one of the prerequisites to becoming a FM teacher, in order to fulfil the same criteria as other teachers at the Medical School. It led to the early establishment of the Department of FM; in 1980, three prominent GPs with doctoral degrees were elected as a core staff of the Department of FM at Zagreb Medical School. The ST curriculum was changed several times, with particularly significant changes happening in 2003/04, but the vision remains the same; the availability of a postgraduate course with a special research module, clinical and FM rotations. The aim of this report is to present our experience in the developing research capacities and to evaluate the outcomes in terms of published articles written by the ST trainees.

Developing research capacities Over 3 years of ST curriculum, out of a total of 900 teaching hours in the postgraduate course, 600 are devoting to direct teaching and 300 hours on individual task-based learning. In the research module, out of 100 hours, 40 are devoted to direct teaching and 60 to work on small research projects under the supervision of mentors with academic degrees. The final requirement is post-graduate diploma work, which should be written and defended in front of three members of a jury. The diploma work is a prerequisite to obtaining a postgraduate degree. Generally, the research module is designed to develop the trainees’ competencies in the posing of a research question, collecting data in response to the question, and presenting and answering the question (1,2,3). However, the entire educational process was divided in smaller modules. Generally the process is initiated with a discussion on the general nature of the problem, or rather, its context within the

46

World Book of Family Medicine – European Edition 2015 research framework in Family Medicine. A group discussion is conducted regarding the importance of the research problem with relation to the ST trainees’ interests and preferable outcomes from their working experience. Following this, a literature review is performed to identify flaws or holes in previous research, which provides justification for the study, and is done individually; each trainee undertaking their own literature-search relevant to his/her research inquiry. They learn that a gap in the current literature, as identified by them, will lead to the formulation of a research question which may be parallel to their hypothesis. In data collecting to test the hypothesis, special attention is paid to selection of appropriate research methods, quantitative or qualitative depending on the research question, as well as sampling methods. Knowledge and skills on the basic statistical methods, important for data analysis and interpreting, are standard content. The education process is organised in an interactive way through a combination of theoretical teaching (lectures, small group discussion) and practical work on the defined task, such as data collection. The last part of the module is related to the writing of diploma work, and different types of articles, including the rules on literature citations and publishing. As mentioned previously, the direct outcomes of the research modules are small research projects completed by each ST trainees, published and defended as diploma work (4). Some of the projects are also published as research papers in different journals and have been presented at the European General Practices Research Network and other conferences (5, 6). Another advantage to such education is the further development of the individual’s research capacity. Whe some of the ST trainees choose to go on to the doctoral study programme lasting three years, this module covers almost one year of the study; and brings him/her 40 ECTS of the 60 ECTS necessary to obtain within one year.

Evaluation Two types of pilot evaluation were performed, one related to the post-graduate diploma works and another related to the number and content of published articles. We carried out analysis of 420 diploma-works (64.5% of total). 82.1% of them are designed as research, 5.2% as literature review, and 12.6% as case presentations. The majority percentage of the content are related to clinical themes (27.9%). 17.4% are related to organizational issues and methods of work in family practice. In 15.5% of them, specific family medicine themes were surveyed, such as co-morbidity, biopsychosocial aspects and palliative care. 10.7% were dealing with patients’ and their health needs. Prior to the start of renewed VT in 2003, 42 articles were published in the official Croatian FM journal by the trainees and subsequently, 71 articles. This accounted for a 69% increase in published articles. 96 articles were published at the Congress Proceeding of the Croatian FM Association prior to renewed VT, and 165 subsequently; an increase in 71.9%. Most of the articles are related to clinical themes (65%), 21% related to FM issues, and around 14% associated with other themes.

Conclusions The results of the pilot evaluation indicated that it was worth the investment of resources in the development of research capacities in FM. We presented Croatia’s model in order to share experiences and to improve overall development of research capacities in Family Medicine consistent with the “Research Agenda for General Practice / Family Medicine and Primary Health Care in Europe” proposed by EGPRN (7).

Take Home Messages 

Research capacities are important for the development of FM as a scientific discipline



It could be undertaken within the ST training



The research topics should be relevant to the ST trainees’ interest and preferably stem from their working experience



The “active” educational methods are needed



The effort is a valuable experience and bring success and satisfaction

Original Abstract http://www.woncaeurope.org/content/research-general-practice-what-and-how-teach

References 47

World Book of Family Medicine – European Edition 2015 1. 2. 3. 4. 5. 6. 7.

Howie FGR. Research Methods in General Practice. Chapman Hall: London, 1989. Armstrong D, Grace J. Research Methods and Audit in General practice. Third Edition. Oxford University Press: Oxford, 2000. Hesse-Biber S, Leavy P. Approaches to Qualitative Research. Oxford University Press: Oxford, 2002. Katić M, Budak A, Vrcić-Keglević M, Blažeković-Milaković S, Bergman-Marković B, Tiljak H, Lazić Đ, Cerovečki-Nekić V, Petriček G, Ožvačić Z. Scientific and research projects of the department of Family medicine: contribution to the identity of general practice as scientific discipline [in Croatian]. Liječ Vjesn 2002;124 (Suppl 2):S32-6. Vrcić Keglević M, Katić M, Tiljak H, Lazić Đ, Cerovečki Nekić V, Petriček G, et al. Specialization in family medicine-has all the planned been achieved? [In Croatian] Acta Med Croatica. 2007;61(1):95-100. Davorka Vrdoljak, Dragomir Petric. A proposal for enhancement of research capacities in Croatian general practice. Acta Medica Academica 2013;42(1):71-79. Hummers-Pradier E, Beyer M, Chevallier P, Eilat-Tsanani S, Lionis C, Peremans L, et al. Research Agenda for General Practice/ Family Medicine and Primary Health Care in Europe. Maastricht: European General Practice Research Network EGPRN; 2009.

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World Book of Family Medicine – European Edition 2015 Donatella Sghedoni, MD [email protected]

14 – An International Comparison of the Role of the Family Doctor in Different Countries and its Consequences on the National Health Outcomes and Expenditures: What has Changed in More than 10 years? Donatella Sghedoni, MD General Practice Unit, Primary Care Services Department , ASL (Azienda Sanitaria Locale) of Milan, Italy Co-authors Maria Enrica Bettinelli, MD, Alberto Donzelli, MD

In the 2002 WONCA Congress (London) Alberto Donzelli, Maria Enrica Bettinelli and I delivered the presentation “An International Comparison of the Role of the GP in Different Countries and its Consequences on the National Health Outcomes and Expenditures”. The authors are MDs, with clinical and organizational specializations, working for the NHS in the continuing education and management of >1000 GPs, in Milan, Italy. We addressed some issues about the organization of primary care in industrialized countries, looking at the available evidence. The GP is the health professional closest to the greatest number of citizens and the only professional who can provide personalized/comprehensive care, including prevention, at reasonable costs. In order to fully accomplish this task, GPs must coordinate and filter the marketdriven increasing technological suggestions, be the patients’ advocate in order to avoid unnecessary medicalisation, as well as consider the community’s needs and attempt to influence the physical/social environment components of the disease. The main issues regarding the GPs’ role, how to finance them and organize the health service are: 

GPs (mainly) gate-keeper vs. direct provider of services



GPs paid by capitation vs. fee-for-service

 Public NHS vs Health insurance-based We considered the economic point-of-view of the NHS and the community’s wider opinion, highlighting the more effective and cost-effective options on the basis of the available health and economic indicators. We chose the reliable, updated Organization for Economic and Cooperation Development/OECD Health database (2001), comparing it now with the 2013 OECD database (1) and others (2). To measure the effectiveness and cost-effectiveness in producing health, we chose some proxy health and economic available indicators. Health indicators were lifeyears lost before 70 years for avoidable mortality; infant mortality; and rates of selected surgical interventions. The main economic indicator was the percentage of the Gross Domestic Product/GDP spent for health in every country, as total and public expenditures. We differentiated the countries according to the different GPs’ role, payment and health system model, with special interest for Italy, where the GPs are gate-keepers, paid mainly by capitation with some incentives, in a NHS. There is still political pressure towards more market and privatization, supposedly more costeffective. In 2002, with the exception of Portugal, the USA had the highest quantity of life-years-lost before 70 among the 49

World Book of Family Medicine – European Edition 2015 examined developed countries; in 2013 their life expectancy is still lower than the average of the 34 OECD countries (78.7 vs 80.1 years) and much lower than Italy, second-best within the whole evaluation (82.7 years). The infant mortality pattern has not changed, with Nordic countries experiencing the lowest rates (2/1000 live births) and around 4/1000 in the other Western European countries and 6.1/1000 in the USA. The reduction in infant mortality has been slower in the USA than in most other OECD countries, with socio-economic/ethnic inequalities playing a significant role. In 2002 the rates of some surgical elective procedures showed regional variations not consistent with any epidemiological pattern, but strongly correlated with the different method of payment of doctors and with the health systems’ organizational structure. This is still valid today. We addressed the question whether a GP is more effective and efficient when he/she is mainly a gate-keeper or a direct provider of services, even when these functions are compounded in the work of European GPs. The Total Health Expenditure was higher in countries without a gate-keeping GP and with direct access to the specialist (i.e. USA, Switzerland, France, Belgium…). The countries with gate-keepers (i.e. Italy, UK, Spain…) spent less and achieved better health results. Since 2002 the European economic situation has deteriorated and health expenditure has abruptly decreased in some countries (Greece), but the main findings seem still valid. If the main source of income and gratification comes from the direct provision of services, especially if highly technological, this could divert GPs from the fundamental role of gate-keeping. Under these circumstances, they must question the appropriateness of many prescriptions or suggestions coming from hospitals or university specialists. The gate-keeping task often makes the doctor-patient relationship problematic, especially if it has not been included in the education and training and is not seen as important or valued by the health system and community. The public should be educated on the value of the gate-keeping function and its ethical significance for a better use of available resources. The direct provision of additional services is usually linked to fee-for-service payments and where they are used the per-person total and public expenditures are higher than where capitation or salary are preferred. Doctors seem to provide the best rewarded services, even if they are aware of their questionable health value (3). The capitation payment should also be preserved for ethical reasons, being more suitable to comprehensive care, prevention included, according to the patient’s needs. It should evolve towards an age-weighted capitation formula with a progression by age, weighted more towards the elderly (and infants) than the young (4). It could be integrated by incentives based on results/levels-of-result, especially in crucial areas such as the anti-smoking and breast-feeding counselling in Italy. The General Medical Contract/GMS for GPs with its related Quality Outcome Framework/QOF, introduced in 2004 in the UK and continually readjusted, showed that the P4P was more expensive than expected because most GPs have reached the fixed goals, concentrating their efforts on the targeted areas only. Our model with a strongly age-weighted capitation is more comprehensive and should avoid the latter. The role of GPs is also preventative; increased financial reward for older patients should encourage every evidencebased preventative efforts to ensure a healthy old age for their patients, avoiding unnecessary diagnostics and treatment, recently defined as “quaternary prevention” (5). To sum up: “A system that pays for health and not for disease”. Comparing Insurance–based and NH services, the total health expenditures are obviously not contained by the former, and such systems are not able to contain the public expenditure, both in the non-profit version (“mutuel”, “Krankenkassen”…) and in the profit ones (private insurance companies) which also have the worst health outcomes.

Take Home Messages 

National health services are still the more effective and efficient health systems



Within them, GPs should have a strong role as gate-keeper



GPs should be paid by a weighted capitation system, integrated by outcome-based incentives



Fee-for-service payments and other systems paying for disease (disease management…) and for processes (pay-for-performance/P4P…) should be dismissed in favour of a system paying for health (and for a long healthy life of the citizens)

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World Book of Family Medicine – European Edition 2015

Original Abstract http://www.woncaeurope.org/content/419-international-comparison-role-general-practitioner-gp-different-countries-and-its

References 1. 2. 3. 4. 5.

http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf http://www.euro.who.int/en/about-us/partners/observatory Brotons C, Bjorkelund C, Bulc M et al. Prevention and health promotion in clinical practice: the views of general practitioners in Europe. Prev Med 2005; 40: 595–601. Donzelli A, Carelli F, Ronchi L et al. A Reform of Rewarding Systems of the Providers and Other Players in Health Care Arena: a Structural Way to Prevent Overdiagnosis and Disease Mongering. Response July, 5, 2012 to: Moynihan R, Doust J, and Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012; 344:19-23 Kuehlein T, Sghedoni D, Visentin G et al., Quaternary Prevention: a task of the General Practitioner - Primary Care 2010;10: Nr. 18 (translated also in German, Italian, French, Spanish, Portuguese and Croatian)

http://www.primary-care.ch/docs/primarycare/archiv/de/2010/2010-18/2010-18-368_ELPS_engl.pdf

51

World Book of Family Medicine – European Edition 2015 William Wong MD (Edin) MPH (CUHK) FRACGP (Aus) FRCGP (UK) [email protected]

15 – Tackling Health Inequalities: the Role of Family Medicine The late Barbara Starfield left us her wisdom, “Inequity is built into health systemsDr. William Wong MD (Edin) especially health systems that are based on a view of health needs disease by disease. MPH (CUHK) FRACGP (Aus) Therefore, the benefits of primary care, which is in person- and population- rather than FRCGP (UK), disease-focused, are under-appreciated. Data provide evidence not only of its benefit to Specialist in Family Medicine, Clinical Associate Professor & populations but also of its preferential benefit to the socially disadvantaged.” (1) Chief of Research, Department of Family Medicine and Primary Introduction Care, The University of Hong Kong, Hong Kong, China Health inequities occur in different socio-economic classes (2), and span across a wide Co-authors: range of socio-cultural characteristics (2-3). Health inequity refers to differences in E Shadmi, Karen Kinder, Iona health that are not only unnecessary and avoidable, but are also unfair and unjust (4). Heath, Michael Kidd Research consistently shows that gaps in health and health care persist, and are even widening (5). Research has repeatedly shown the strength of a country’s primary health care system and its primary care attributes significantly improves populations' health and reduces inequity (6-7). Starfield et al identified the primary care attributes that contribute to population health, including first contact access, greater focus on prevention, provision of person-focused comprehensive care, with greater continuity and coordination (7). Such attributes are of special importance to inequity reduction as the socially disadvantaged have a greater likelihood of occurrence, severity, and adverse effects in multiple illnesses for which a comprehensive, coordinated, personfocused primary care (rather than a speciality driven, disease-focused) view of morbidity can be more effective (1). Recent evidence also supports the above conclusions showing that primary care can reduce inequity in developed as well as in low and middle-income countries. A review that assessed the contribution of large primary care initiatives to a broad range of health system goals in low and middle-income countries concluded that primary carefocused health initiatives had improved access to health care, including among the poor, at reasonably low cost and primary care programs had reduced child mortality and, in some cases, wealth-based inequity in mortality (8).

Current Health Inequity Issues Faced by Primary Care Practitioners (PCP) As a foundation step for the establishment of WONCA's first Health Equity Special Interest Group, The World WONCA held a workshop on health equity during its biannual meeting in Prague on 26-30 June 2013 with the aim of exploring how a better understanding of health inequities could enable PCP to adopt strategies that could improve health outcomes through the delivery of primary health care. It was attended by 120 delegates from across the globe, including developed as well as low and middle-income countries. Following the presentations, workshop attendees were asked to participate in small group discussions and were asked to rate on thirteen possible inequity reduction activities 52

World Book of Family Medicine – European Edition 2015 on a 1-5 Likert scale in an anonymous survey. In the small group discussions, they recognized in their own setting how uneven distribution of social determinants of health could have affected poor health outcomes such as life expectancies and risk behaviours, and how health systems that had operated in different countries could have systematically affected people’s affordability as well as access to healthcare services and fundamental rights to good health. They identified health workforce shortage, lack of communications between primary & secondary care, low political incentive and priority for marginalized populations as well as low health literacy and expectation of the patients as contributions in meeting the health equity agenda. They believed signposting for how to navigate the healthcare system and training should be provided to leaders of vulnerable groups since community awareness should be provided to the public as well as the patients. Furthermore, they believed that training in inequity should be provided to medical students as well as PCP on how to improve health equity through primary care. Overall, the participants rated the degree to which their country currently had utilized the various mechanisms to reduce health inequity as “moderate” (mean: 2.85, standard deviation (SD): 1.12). The results indicated that the types of mechanisms most commonly utilized included: promoting access to primary care (mean: 3.63, SD: 1.24); initiation of public health programs to promote health equity (mean: 3.17, SD: 1.01); and, promoting access to care by increasing coverage (mean: 3.12, SD: 1.36). The activities least practised were: engagement in cross-national collaborations to promote health equity (mean: 2.12, SD: 0.99); promoting research on health equity (mean: 2.40, SD: 1.04); and, reforming medical education to incorporate health equity and cultural competency training (mean: 2.44, SD: 0.96). On average, participants rated the degree to which they had believed the items representing priority areas which countries should be engaged in as “high” (average: 3.85, SD: 0.88). Practices most commonly viewed as useful were: promoting the availability of primary care services (mean: 4.68, SD: 0.63); and, initiation of primary care programs to promote health equity (mean: 4.42, SD: 0.76).

How Could PCP Help in this Movement? In view of these findings and enthusiasm within the profession, the Health Equity Special interest group (SIG) was proposed and approved by the WONCA Executive in early 2014 bringing the essential experience, skills and perspective of interested PCP around the world to address the differences in healthcare that are unfair, unjust, unnecessary but avoidable. It is hoped this group will use WONCA as a platform for exchange of ideas, advice, support and advocate for better equity in health. The WONCA Health Equity SIG plans to contact and work with existing centres on health equity; to provide news updates and events related to health equity; to conduct/facilitate literature review on research gaps; to collaborate/identify/set up a resource centre on health equity; to organise regional/international workshops/ seminars to keep up with the health equity agenda; and, to formulate a framework within a medical curriculum on health equity. Interested parties should visit: http://www.globalfamilydoctor.com/groups/SpecialInterestGroups/HealthEquity.aspx for further information.

Take Home Messages 

Despite evidence of the contribution of the core attributes of primary care to populations’ health and reduction of inequity, inconsistencies are found in implementation of primary care features in different countries, with greater emphasis on the provision of easily accessible primary care and less investment in promoting programmes to improve continuity or coordination.



Health equity workshop participants expressed similar assessments regarding their countries’ priorities, indicating that promoting access (availability and coverage) of primary care services was more often performed than initiating tailored primary care interventions (mean score: 3.04-3.63, compared to 2.96, respectively).



Importantly, survey respondents identified “promoting access to primary care services” as the most important priority that countries should engage in.



Activities that have been previously cited as important for promoting equity in health i.e., reform in medical education, promoting research, and fostering cross-national collaborations, were identified by survey respondents as low current priorities in their own countries.



Assessment of the gaps between current and preferred priorities showed that to bridge expectations and

53

World Book of Family Medicine – European Edition 2015 actual performance, countries should engage in forming cross-national collaborations; incorporate health equity and cultural competency training in medical education; and, engage in initiation of advocacy programs that involve major stakeholders in equity promotion policy making as well as promoting research on health equity. This article is a modified version of the manuscript published at the International Journal of Health in Equity (http://www.equityhealthj.com/content/13/1/104).

Original Abstract http://www.woncaeurope.org/content/28-tackling-health-inequalities-role-general-practice

References 1. 2. 3. 4. 5. 6. 7. 8.

Starfield B. The hidden inequity in health care. International journal for equity in health. 2011;10:15. WHO. Closing the gap in a generation: Health equity through action on the social determinants of health. 2011; www.who.int/social_determinants/final_report. Accessed November 20, 2013. Marmot M, Allen J, Goldblatt P, et al. Fair Society, Healthy Lives. The Marmot Review. 2010. Whitehead M. The concepts and principles of equity and health. International journal of health services : planning, administration, evaluation. 1992;22(3):429-445. Bleich SN, Jarlenski MP, Bell CN, LaVeist TA. Health inequalities: trends, progress, and policy. Annual review of public health. Apr 2012;33:7-40. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health services research. Jun 2003;38(3):831-865. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. The Milbank quarterly. 2005;83(3):457-502. Kruk ME, Porignon D, Rockers PC, Van Lerberghe W. The contribution of primary care to health and health systems in lowand middle-income countries: a critical review of major primary care initiatives. Social science & medicine (1982). Mar 2010;70(6):904-911.

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*

The level to which this activity is currently part of respondent's countries' key priority issues (1-5)*, M±SD

The level to which this activity SHOULD be part of respondent's countries' key priority issues (1-5)**, M±SD

Initiation of advocacy programmes to involve major stakeholders in equity promotion policy making

2.71±1.08

4.35±0.75

Reform of medical education to incorporate health equity and cultural competency training

2.44±0.96

4.19±0.83

Promote research on health equity

2.40±1.04

3.96±0.85

Initiate public health programmes to promote health equity

3.17±1.01

4.22±0.89

Initiate primary care programmes to promote health equity

2.96±1.04

4.42±0.76

Promote access to care – availability of primary care services

3.63±1.24

4.68±0.63

Promote access to care- increased coverage of services / health insurance

3.12±1.36

4.20±1.12

Promote access to care- point-of- service free care

3.04±1.06

4.08±1.08

Promote the collection of socio-demographic data on patients in a routine and standardized way

3.07±1.46

3.82±1.31

Write guidelines for physicians for health equity promotion

2.70±1.23

3.74±1.13

Promote the development and implementation of tools to measure and monitor inequity in health

2.73±1.12

4.11±0.70

Promote diversity in medical workforce

2.96±1.19

4.04±0.84

Engage in cross-national collaborations to promote health equity

2.12±0.99

4.08±0.91

1=Currently not a priority; 5=Currently a top priority.

**

1=SHOULD not be a priority; 5=SHOULD be a top priority

55

World Book of Family Medicine – European Edition 2015 Harris Lygidakis, MD [email protected]

16 – Using the Internet to Answer Clinical Questions Harris Lygidakis, MD Vasco da Gama Movement Immediate Past Chair, Bologna

“Medicine has built on a long history of innovation […] Doctors have embraced each new technology to advance patient care. But nothing has changed clinical practice more fundamentally than one recent innovation: the Internet.” - Pamela Hartzband and Jerome Groopman (1) Evidence-based Medicine became widely accepted at the same time that the World Wide Web was rapidly expanding and the development of online databases was making information easily available. Nowadays, healthcare professionals are increasingly using the Internet to obtain current health and medical information, and access journal articles and synthesis of evidence-based information. However, there is relatively limited research on the healthcare professionals’ online searching methods and behaviour, especially in real-world settings, beyond the academia’s strict models (2). The plethora of information readily available on the Internet has gradually shifted the focus to how well we are able to search, filter and appraise the most relevant, accurate and reliable information and how efficiently and appropriately we are able to handle and apply it in clinical practice. Retrieving information from the Internet necessitates specific skills and the outcome depends on the user’s ability to access catalogues and databases, and employ an effective search strategy. Besides the essential digital literacy which is considered to be commonplace among young physicians, healthcare professionals are also required to be trained in order to translate their need for information into a properly structured and “answerable” query (3). Systems using natural language and semantic tagging are under development and promise to change the way we seek and obtain information. Although almost three out of four physicians who seek out medical information on the Internet state that they begin their research with a generic search engine, such as Google (4), other research suggests that healthcare professionals prefer more specific resources, like Pubmed and WebMD (5). There are still a significant number of online resources that require paid subscriptions, restricting the fair dissemination of medical knowledge. Time also represents a major constraint: healthcare professionals have very little amount of time available to search the Internet for the current best information. With medical knowledge and literature expanding rapidly, there is a negative impact on how healthcare professionals are seeking and managing information, leading to misinterpretation of the evidence, acceptance of lower-quality information and resignation (3).

Social Networks 56

World Book of Family Medicine – European Edition 2015 Despite the exponential growth of medical information available on the Internet, many healthcare professionals still turn to colleagues and trusted experts as their first resource (2). With the advent of the 2.0 era, these resources are being replaced by global networks, where information-seeking and appraisal can be crowd-sourced. Although social networking should function as a companion in the search for the best available evidence, by investing in the development of a trustworthy network, healthcare professionals can reach out to the world and have information at their fingertips. Besides employing generic-purpose social networks, they can also use those relevant to the medical sector, such as Doximity, Sermo and doc2doc, which offer more controlled and possibly safer environments. What is more, in this era of brewing participatory culture they are also given the opportunity to curate content themselves and open up to a dialogue not only with their peers, but also with professionals from various settings and with different backgrounds and expertise.

Information Seeking and Healthcare Users As health information is becoming widely accessible and growingly reliable, patients are increasingly interested in learning about their conditions, their prevention and treatments, and sharing their experiences. They seek online health information, connect and collaborate with the others and take advantage of the Internet not only for decisionmaking and management of their own condition, but also for education and advocacy purposes. In fact, according to the Pew Research Centre, 7 out of 10 Internet users in the United States searched for health-related information in the span of a year and one in three adults looked online to diagnose a condition (6). Remarkably, 30% of the older people sought health-related information as well. For the first time, as Eric Topol mentions, the medical world is getting democratized (7) and the flow of information is leading to a paradigm shift of the patient and healthcare professional roles. As patients face the overwhelming and often conflicting body of available information, it is becoming common practice for them to bring such information to consultations in a quest to analyse and comprehend it. Patients in fact, are increasingly relying on their physicians for the interpretation of the online information (5). It is therefore becoming increasingly essential that not only should healthcare professionals embrace this need and accept this behaviour, but they should also guide their patients and refer them to reliable online resources.

Take Home Messages 

 

Healthcare professionals are increasingly using the Internet to obtain current medical information and are gradually focusing on how well they are able to search, filter and appraise the most relevant, accurate and reliable information and how efficiently and appropriately they are able to handle and apply it in clinical practice. Information-seeking and appraisal can be crowd-sourced with the use of social networks, where physicians can also curate content and converse with professionals around the globe. As patients seek online health information, and connect and collaborate with others on the Internet, healthcare professionals should be able to help them interpret such information and guide them to reliable online resources.

Original Abstract http://www.woncaeurope.org/content/3550-using-internet-answer-clinical-questions

References 1. 2. 3. 4. 5.

Hartzband P, Groopman J. Untangling the Web--patients, doctors, and the Internet. N Engl J Med. 2010;362(12):1063-6. doi: 10.1056/NEJMp0911938. PubMed PMID: 20335581. Younger P. Internet-based information-seeking behaviour amongst doctors and nurses: a short review of the literature. Health Info Libr J. 2010;27(1):2-10. doi: 10.1111/j.1471-1842.2010.00883.x. PubMed PMID: 20402799. Clarke MA, Belden JL, Koopman RJ, Steege LM, Moore JL, Canfield SM, et al. Information needs and information-seeking behaviour analysis of primary care physicians and nurses: a literature review. Health Info Libr J. 2013;30(3):178-90. doi: 10.1111/hir.12036. PubMed PMID: 23981019. Lewis Dolan P. 86% of physicians use Internet to access health information. Am Med News [Internet]. 2010. Available from: http://www.amednews.com/article/20100104/business/301049966/7/ . Higgins O, Barry M, Dmegan C. A literature review on health information seeking behaviour on the web: a health consumer and health professional perspective. European Centre for Disease Control, 2011.

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World Book of Family Medicine – European Edition 2015 6. 7.

Susannah F, Maeve D. Health Online 2013. Pew Research Center’s Internet & American Life Project, 2013. Topol E. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic Books; 2012.

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World Book of Family Medicine – European Edition 2015 John Sandars [email protected]

17 – Threats to Patient Safety in Primary Care: A Review of the Research into the Frequency and Nature of Errors in Primary Care John Sandars MD Professor, Academic Unit of Medical Education, The Medical School The University of Sheffield

This WONCA Conference presentation was based on a literature review that had been sponsored in 2001 by the Department of Health in the UK. Several databases were systematically reviewed, the key findings of which showed that medical error occurred between five and 80 times per 100,000 consultations, and these errors were mainly related to the processes involved in diagnosis and treatment (1). Prescribing and prescription errors were identified to occur in up to 11% of all prescriptions, and these were mainly related to errors in dose. An important aspect of this review was to highlight firstly, the wide variety of definitions of the various threats to patient safety that were used to identify the frequency and nature of these threats and secondly, the different methods used to identify threats to patient safety. These findings are of great importance if a comprehensive understanding of the frequency and possible causes of threats to patient safety is to be obtained. This understanding is essential for making appropriate interventions, including policies and protocols, to reduce threats to patient safety, with the ultimate aim of improving patient care. The main approaches to identifying threats to patient safety are incident reporting, systematic identification (such as by observing clinical practice), and medico-legal and patient complaint databases and qualitative interviews. All of these approaches reveal different aspects since some of the events may, or may not, have caused actual harm and the identification may only be through mandatory reporting, with greater emphasis on the less common but more serious events. Overall, the variety in the reported frequency and type of threat to patient safety depends on the different perspectives obtained from family physicians, primary health care workers and patients. A recent study has confirmed these findings, noting that patient surveys identified the highest number of events and pharmacist reports for the lowest number (2). Many of these events reported by patients are likely to have caused minimal harm but can be regarded as an indicator of potential causes of more serious threats to patient safety. The causes of threats to patient safety are usually a combination of inter-dependent factors (3). A study in primary care found that about half of the threats to patient safety were due to “situational” factors and that these events were often linked to serious potential consequences. The most frequent contributing factor was the organisation of work in primary care, including the excessive demands of working in a complex clinical environment, as well as the fragmentation of healthcare across the variety of different health care providers in primary care (4). Dealing with complexity is typical of the work of primary care and it is not surprising that this factor is a major contributory cause of threats to patient safety. A recent

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World Book of Family Medicine – European Edition 2015 study in the UK found that there was a risk of eight adverse events per 10 000 consultations, and that the highest risk were in patients aged 65–84 years, in patients who frequently consulted, patients who had five or more emergency admissions and in those patients who had the most diseases recorded (5). It is also interesting to note the findings of a review of international malpractice claims (6) .The most common reason for a claim was associated with failure to, or delay, in diagnosis, especially missed or delayed diagnoses included cancer and myocardial infarction in adults and meningitis in children. Medication error was the second most common reason for a claim. Threats to patient safety continue to be a priority for all healthcare systems, including primary care. The increasing recognition over the last 20 years that these threats are associated, and probably to some extent inevitable, when working in a complex clinical environment should turn attention of all stakeholders to the important “situational” factors. The approach should be to minimise the impact of these factors on the process of healthcare, such as ensuring doctors recognise when they feel under stress, developing clinical decision-support systems and empowering patients to speak out during the process of their care.

Take Home Messages 

Estimates of the frequency and nature of threats to patient safety in primary care vary widely due to differences in definition and method of identification, with patient surveys identifying the highest number of threats to patient safety



The most common causes of threats to patient safety in primary care are related to making a diagnosis and using medication.



Recent research highlights the importance of factors associated with the complexity of providing primary care, such as elderly patients with co-morbidities and early diagnosis of serious diseases, to threats to patient safety in primary care.



The importance of “situational” factors, such as work-load stress and fragmentation of care across different healthcare providers, is increasingly recognised as contributing to threats to patient safety in primary care.



Reducing threats to patient safety in primary care requires an awareness of the different inter-related factors that occur with the complexity of the provision of primary care and requires a variety of appropriate interventions, including empowering patients to speak out during the process of their care.

Original Abstract http://www.woncaeurope.org/content/53-threats-patient-safety-primary-care-review-research-frequency-and-nature-errorsprimary

References 1. 2. 3. 4. 5. 6.

Sandars , J., Esmail, A., (2003). The frequency and nature of medical error in primary care: understanding the diversity across studies. Family Practice, 20(3), 231-236. Wetzels, R., Wolters, R., van Weel, C., & Wensing, M. (2008). Mix of methods is needed to identify adverse events in general practice: a prospective observational study. BMC family practice, 9(1), 35. doi:10.1186/1471-2296-9-35 Sandars, J., & Cook, G. (Eds.). (2009). ABC of patient safety. John Wiley & Sons. Kostopoulou, O., & Delaney, B. (2007). Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors. Quality and Safety in Health Care, 16(2), 95-100. doi:10.1136/qshc.2006.020909 Tsang C1, Bottle A, Majeed A, Aylin P. Adverse events recorded in English primary care: observational study using the General Practice Research Database Br J Gen Pract. 2013 Aug;63(613):e534-42. doi: 10.3399/bjgp13X670660. Wallace, E., Lowry, J., Smith, S. M., & Fahey, T. (2013). The epidemiology of malpractice claims in primary care: a systematic review. BMJ Open 2013;3:e002929 doi:10.1136/bmjopen-2013-002929

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World Book of Family Medicine – European Edition 2015 John Yaphe MD [email protected]

18 – Teaching and Learning about Uncertainty in Family Medicine John Yaphe MD Associate Professor, Community Health, University of Minho, Portugal

Uncertainty is a fact of life. We face many kinds of uncertainty in medicine: uncertainty about diagnosis, tests, treatments, and outcomes. There is financial, political, and organizational uncertainty in health services. All this is in addition to uncertainty in our daily lives. Acceptance of uncertainty can help us develop coping strategies in the low-tech, hightouch world of Family Medicine. We can teach this to our students and trainees and hone this throughout our careers. Does uncertainty make us ask more questions, order more tests, prescribe more treatments, make more referrals, and do more surgery? Does it lead us to take time for personal reflection and discussion with colleagues, patients and their families? It is worth exploring this field and considering new directions for research. Attitudes to uncertainty have shifted from attempts to master or diminish uncertainty to efforts to cope with it. Many accept and celebrate that things remain uncertain. Uncertainty can be tolerated (1). By sharing responsibility with the patient we can make it easier on ourselves. Long-term relationships in family medicine and close follow-up allow us to use time as a diagnostic and therapeutic tool. This may reduce anxiety in both doctor and patient from the initial visit. Uncertainty arises in primary care at the point of first contact with the medical care system (2). Patients appear with undifferentiated symptoms. A patient-centred approach, focusing on understanding the patient’s reasons for consulting, may help. The doctor-patient relationship is an important tool for managing uncertainty. Shared decision-making affects doctors’ feelings of uncertainty and their willingness to disclose this to patients (3). Anxiety may be related to gender and be more prevalent among younger doctors. Willingness to learn about shared decision-making increases comfort through sharing uncertainty with patients. Training can help people to cope with the inevitable uncertainty of practice. Consider a 30 year-old man who comes to the family doctor with low back pain of three days’ duration, after heavy lifting at home. The neurological examination is normal. When doctors are asked how certain they are of their diagnosis and that their usual treatment would help the patient in this scenario, figures are high on both counts. When they subsequently learn that this patient had a history of successful treatment with radiotherapy and chemotherapy for Hodgkin’s disease ten years earlier, assessments of certainty fall. Context is everything. Uncertainty also plagues our patients. Patients with chronic obstructive lung disease face ambiguity, defined as a lack of understanding of symptoms, and complexity, defined as lack of understanding of treatment (4). Criticism from family members increases uncertainty while participation in patient support groups helps patients by decreasing uncertainty. Research into patient self-help groups and their effects on uncertainty and self-efficacy might be useful.

Uncertainty may represent hope to patients. We need to recognize and validate uncertainty in our patients concerning

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World Book of Family Medicine – European Edition 2015 breast self-examination (BSE) (5). BSE increases anxiety without decreasing morbidity or mortality from breast cancer. Teachers also feel uncertain (6). They may ask: how much do my students know and understand, how effective is my teaching, how can I best use the limited time I have with students and what intellectual and social authority do I have to teach? Too much uncertainty in the classroom can lead to anarchy while too little uncertainty can lead to dogmatism. Medical students appreciate that we can’t know it all, we don’t know everything, and we can’t even agree on what we think we know. We help our students by listening to their concerns, helping them to ask questions, strengthening their healthy coping mechanisms, providing information they need, and simply by being there for them. Are evidence-based medicine and computers sufficient to lift the smog of uncertainty (7)? Technology and data are not enough. We work in complex systems on the edge of chaos (8). Strategies for coping with uncertainty may include shared reflection of narratives in Balint groups. Research may tell us how much uncertainty plays a role in our clinical encounters and describe the ways patients and doctors cope. We should assess the consequences of uncertainty, including costs. We need to understand the meaning of uncertainty in the unique context of family medicine. The results of research in this field will certainly be helpful to us.

Take Home Messages 

Uncertainty is a fact of life in Family Medicine.



We can tolerate, accept, manage, and even celebrate uncertainty.



A patient-centred approach and long-term relationships can help us cope with uncertainty.



Patients may value uncertainty because it gives them hope.



Research will help us understand how we cope with uncertainty and what this means to medical care.

Original Abstract http://www.woncaeurope.org/content/73-teaching-uncertainty

Conflict of interest: None reported This essay first appeared in another format in The Portuguese Journal of Family Medicine in 2014. It is reprinted with permission.

Dedication It is dedicated to the memory of Dr. Ivar Ostergaard, the original co-author of the workshop on uncertainty presented at the WONCA 2001 conference in Tampere.

References 1. 2. 3. 4. 5. 6. 7. 8.

Thomson GH. Tolerating uncertainty in family medicine. J R Coll Gen Pract. 1978 Jun;28(191):343-6. Biehn J. Managing uncertainty in family practice. Can Med Assoc J. 1982 Apr 15;126(8):915-7. Politi MC, Légaré F. Physicians' reactions to uncertainty in the context of shared decision making. Patient Educ Couns. 2010 Aug;80(2):155-7. doi: 10.1016/j.pec.2009.10.030. Epub 2009 Nov 30. Hoth KF, Wamboldt FS, Ford DW, Sandhaus RA, Strange C, Bekelman DB, Holm KE. The Social Environment and Illness Uncertainty in Chronic Obstructive Pulmonary Disease. Int J Behav Med. 2014 Jul 10. [Epub ahead of print] Babrow AS, Kline KN From "reducing" to "coping with" uncertainty: reconceptualizing the central challenge in breast selfexams. Soc Sci Med 2000 Dec;51(12):1805-16 Floden, RE, Buchmann, M. Between Routines and Anarchy: Preparing Teachers for Uncertainty. Occasional Paper No. 138. 1992 The Institute for Research on Teaching, Colege of Education, Michigan State University, East Lansing, Michigan 48241034 Djubekovic B. Lifting the fog of uncertainty from the practice of medicine. BMJ. 2004 Dec 18;329(7480):1419-20. Tudela M, Amado Lobo F, Ramos V. Desafios da complexidade em medicina geral e familiar. (Challenges of complexity in

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World Book of Family Medicine – European Edition 2015 general practice) Rev Port Clin Geral, 2007, Vol. 23, Nº 6, 715-725.

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World Book of Family Medicine – European Edition 2015 Paul Van Royen, MD, PhD [email protected]

19 – Home Visits: are they Useful or Necessary in Family Medicine? Paul Van Royen, MD, PhD Professor of General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Belgium

Introduction In most European countries home visits form part of the family doctors’ (FD) normal routine. However, the chance of receiving a home visit by a family doctor varies widely across Europe. In the Nineties, the percentage of home visits was high in several European countries, such as Belgium, Germany and France (1). But also in East European countries, such as Moldavia, the percentage of home visits varied from 35 to 40 %, taking up the majority of the doctor’s time (2). However in health care systems with a patient list system and payment by capitation, there were fewer home visits. Especially in Scandinavian and Mediterranean countries, family doctors had a low frequency of home visiting (1).

Necessity of Home Visits – Their Added Value, Disadvantage and/or Benefit Versus an Office Encounter There is a debate about the value of home visits and the appropriate rate. Patients seemed to like home visits more than family doctors did, and it is likely that this is often the deciding factor , as stated by several authors (1, 2). There is little debate about the family doctor's role in performing a home visit when patients are restricted in their mobility, especially for the elderly and very ill patients. But there are constraints. Home visits are time-consuming (double time compared to office consultation), less efficient (because of less favourable clinical situations for diagnostic and therapeutic interventions) and not always safe to realise, especially in the evening and night. Quantitative research revealed that doctor-related factors, the organisation of the healthcare system and to a lesser extent, patient characteristics were explanatory factors for the high number of home visits (3). In Belgium, qualitative focus group research was conducted with family doctors, patients and representatives of health insurance companies, in order to list all added values, disadvantages of home visits by family doctors – and to explore the factors in determining the request and performance of home visits (4). In total, 77 items were identified, classified into 8 categories of a theoretical framework. Besides different patient groups/illnesses, health care organisation and doctor-related factors, other factors were also revealed – such as patient related factors (convenience for the patient), practice organisation (waiting times, appointment systems), context and intimacy (closer relationship), medical/technical factors and economic factors (cost of a home visit). The additional value of home visits was reported as the understanding gained from meeting the patients on their own territory and the observation of the home situation.

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Decreasing Rate of Home Visiting by Family Doctors In order to change the rate of home visits, an analysis of the necessity of home visits in countries such as Moldavia and Belgium was a first step. This stimulated intervention at the level of practice organisation, for example, in providing an easily accessible appointment system, repeatedly asking patients to come to the surgery and reduction in waiting times. In addition, both patients and health care providers need to alter their view of home visits. There has been a clear decline in family doctor home visits over the past two decades. The decrease of the number home visits performed was remarkable, for instance in Moldavia from 30 % in 2003 to 12 % in 2005 (2). Especially urgent house calls are increasingly delegated to the emergency services, whereas home visits to nursing homes are often characterised as emotionally stressful (5). The question arises whether these changes have really had a positive influence on the quality of medical services. When asking family doctors, they are convinced that they have to ensure quality home care but they are unable to suggest how this might be achieved (5).

Home Visits in the After-hours of Primary Medical Care Furthermore, the organization of after-hours primary medical care services in many European countries is changing. The development of out-of hours cooperatives combined with telephone triage seem to decrease the home visiting rates (6), while deputizing services seem to increase home visiting rates. The circumstances of after-hours primary medical care could possibly give inspiration to daily primary care.

Other Professionals Since family doctors are increasingly working within multidisciplinary teams, home visits are not just performed by family doctors but are increasingly redistributed from the family doctor to other qualified members of the healthcare team such as nurse practitioners or specially trained nurses (7). Their role is important in improving, for instance, the safety of medication management among older persons- but also in (tele) monitoring for different chronic diseases. Multiple programmes have shown to be effective. Informal caregivers are also taking up roles, which were previously undertaken by health care professionals and/or family doctors. They look after and provide help and support to family members, friends and neighbours because of their long-term physical or mental ill health/disability or problems related to old age. Collaborative approaches and redistribution of tasks could probably be the response to the challenging demand for ensuring quality home care in future.

Conclusion Despite the increase of chronically ill and elderly patients, the home visiting rate by family doctors is declining in all European countries. Home visits remain a central element of primary care, especially for the increasing vulnerable patient group. Primary care should reflect on how to ensure this essential service, regarding changing contexts.

Take Home Messages 

Although the home visits rate has declined over the past two decades, home visits remain an important component of family doctors’ routine and workload.



Many factors influence the request and performance of home visits by family doctors: doctor- related factors, practice organisation, contextual information and patient-related factors are the most important reasons to perform home visits.



Family doctors have an important role in performing a home visit when patients are restricted in their mobility, especially in relation to the elderly and the very ill.



Other healthcare professionals and informal caregivers have to take up roles in home care for and home visiting to the disabled and elderly, in order to ensure quality home care in future primary care.



Collaborative approaches and redistribution of tasks are good answers to the challenging demand for ensuring quality home care in future.

Original Abstract

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World Book of Family Medicine – European Edition 2015 http://www.woncaeurope.org/content/cf73-home-visits-medical-necessity-or-simply-service

References 1. 2. 3. 4. 5. 6. 7.

Boerma W, Groenewegen P. GP home visiting in 18 European countries. Eur J Gen Pract. 2001;7:132-7. Nemerenco A. Home Visits- A medical necessity or simply a service? 12th Regional Conference of Wonca Europe ESGP/FM; Firenze: Abstract book 2006. p. 56. De Maeseneer J, De Prins L, Heyerick J. Home visits in Belgium: a multivariate analysis. Eur J Gen Pract. 1999;5(1):11-4. Van Royen P, De Lepeleire J, Maes R. Home visits in general practice: an exploration by focus groups. Arch Public Health. 2002;60:371-84. Theile G, Kruschinski C, Buck M, Müller C, Hummers-Pradier E. Home visits - central to primary care, tradition or an obligation? A qualitative study. BMC Family Practice. 2011;12:24. Philips H, Remmen R, Van Royen P, Teblick M, Geudens L, Bronckaers M, et al. What's the effect of the implementation of general practitioner cooperatives on caseload? Prospective intervention study on primary and secondary care. BMC Health Serv Res. 2010;10:222. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005;18(2):CD001271.

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World Book of Family Medicine – European Edition 2015 Ulrich Busch, MD [email protected]

20 – Promoting the Health and Well-being of Family Doctors -Guerilla Tactics for Family Doctors Ulrich Busch, MD MU Vienna Lect., Grosskrut, Austria Co-author Carl Steylaerts, MD

Physicians are well known to be very reluctant to have a family doctor –but every GP needs a GP! They don't feel the need to have a competent medical “second opinion” or just a routine monitoring of their health. They know it all – and who would trust another doctor?! We decided to tackle this issue as a Military Operation –the doctor as his own enemy and feeling surrounded by enemy colleagues. Sometimes when your day was fully packed fighting infectious and non-infectious diseases, fighting against insurance companies’ bureaucracy, struggling with technical problems in your computerized office, never finding the right specialist at the right time when you need him/her, then one can feel forsaken from the protecting crowd of medical doctors. In your Forward Command Post, with limited low cost armaments, as near as possible to your entrusted patients, that´s where your graduate and postgraduate Training someday comes to an End. Once you realize that the people are the key to be secured and defended rather than the conquest of new Scientific Territory, you will seek new strategies to carry on. Guerilla Tactics for Family Doctors focuses on low-cost strategies to guarantee one’s own healthy survival. These Guerilla Tactics were surely never taught at any medical College, or at the University…

Strategies for Survival Acquire Dogs & Training Since scientists left their Offices and followed Timber Wolves to the woods, we begin to understand why dogs are the most successful companions of Mankind. They developed a rich Body Language or “Calming Signals“, easily understood by any Dog worldwide, and by humans! If you want something to be done by a dog, it´s mostly a question of motivation! Dogs immediately show their Feelings and Emotions to the pack and seem to balance Signs of Stress and Discomfort very quickly in order to avoid stress (Turid Rugaas). A Dog wants to get out no matter what the weather and enjoys your sporty companionship very much. Communicating with this species focuses on the understanding of Body Language and a few Words. And by looking at the dog, you know who’s boss (‘What the Dog Saw’, Malcolm Gladwell). Photography A doctor should have fundamental knowledge of taking a picture. As doctors, we are obliged to focus on Light, to help People out of their unknown Darkness of their Complaints: The more you see, the more you learn, the more you learn, the more you see (Aldous Huxley). Go buy a good Camera! Reframe your Picture of yourself as a GP on a regular base. Be aware that you only get the inside-out

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World Book of Family Medicine – European Edition 2015 view. Once in a while, you should also practice the art of looking outside-in (Kahneman). Try to relax and condense a moment of time, freeze a movement, a notion, catch an emotion with your lens. Then store it and refresh every bit of these pictures. You might try some photoshopping once in a while. Delete what you don't like, sharpen the edges, give a little more contrast when it's lacking, be the director. Dancing Dancing offers Family Doctors a whole new world of a worldwide fully accepted Concept of Interaction with our Patients and Fellow Colleagues of other Disciplines. The Euract “Bled” Courses in Slovenia offer Family Doctors dancing lessons! In our daily consultations we mostly perform a Pas de Deux. Compliance and Adherence are about Leading and Following, and getting into ones Stride. It´s a fine School of humour in our attempts to follow the Rhythms of Life. Sometimes you're invited for a Quickstep, the next patient is in for a Tango, the next one likes to Waltz you around and a day without a Rumba is a day not lived. All this dancing can exhaust you, and at the end of the day all you want is to skip along Fandango on a Whiter Shade of Pale with your life partner. Haute Cuisine Some Principles in Cooking are compatible with our prescriptions /interventions: please take a close Look at the local Food Traditions. Exchange Recipes! Ask your patients in which season and how to prepare the Fresh Food when you are rewarded with it at your Office. Train your Nose and your Senses of Taste for the Joy of Life not only for the cure of illnesses. Lucky you when your dog is under-the-table to protect you from: Medicus Medico Lupus est! Sailing Some principles of sailing are also very useful. If the wind is coming straight from behind, just go straight out – if that is the direction you want to go. If the wind is from one of the sides, you can still go straight out without manoeuvring a lot. If the wind is opposite to you, and you decide not to go with the flow, then you need to tack. If the wind is changing a lot, you need to adjust your course and tacking. Always know your goal. Tides and winds are just as easy to play with as coping with life and its doings. In your Network it’s the knots not the mesh! Sail fast and live slow in the seas of Love! Symphonic Symphonic thinking is an art that is very useful in your daily life as well as in your daily practice. A symptom or a complaint might be a note, it might be a tune, it might also contain a whole song or harmony. Train your ears in discerning what you hear – or don't. Think of remedies or solutions as of symphonies: there is more than one music player at work, although the solo of an instrument can do wonders – if it is well timed and perfectly orchestrated. All players are equal, as equal as the slowest or worst or atonal player. See to it that you know what you are directing – and to what it should lead: a wonderful piece of Bach or Beatles. Engage yourself in the way of lateral thinking and listening what´s between the lines due to celestial strings!

Conclusion Lucky you living in the countryside, if you´ve found a wonderful Partner for Dancing, a Dog as your Personal Fitness Trainer, and a friendly Photographer/ friend who takes your picture and lets you look outside in. Lucky you if you can sail on symphonic thoughts. The Art of practising these touches of Guerilla Tactics in Dog Training, Cooking, Dancing, Sailing and Taking Pictures while playing music is taught in the University of Life, and patients, partners and students help us in developing skills, motivation, feedback and in maturing together.

Take Home Messages 

Try to be in a good physical condition / shape.



Learn from other species how to teach on the basis of motivation rather than of paternalistic, maternalistic, pillistic ways.

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World Book of Family Medicine – European Edition 2015 

Reflect your Life with Friends and professionally with Balint Groups.



Be sure that your partner supports your wish to become a real good (rural) GP

Original Abstract http://www.woncaeurope.org/content/37-pa-education-promote-health-and-well-being-family-doctors

References      

E. Paul Cherniack and Ariella R. Cherniack, The Benefit of Pets and Animal-Assisted Therapy to the Health of Older Individuals. Arch Gerontol Geriatr. 2006 Mar-Apr;42(2):207-16. Epub 2005 Sep 26. Maskarinec GG, Look M, Tolentino K, Trask-Batti M, Seto T, de Silva M, Kaholokula JK. Patient Perspectives on the Hula Empowering Lifestyle Adaptation Study: Benefits of Dancing Hula for Cardiac Rehabilitation. Health Promot Pract. 2014 Mar 27. [Epub ahead of print] PMID: 24677383 Zhang J, Li C, Smithson A, Spann E, Ruan F. Culture and importance of backgrounds: a cross-cultural study of photograph taking. Psychol Rep. 2010 Oct;107(2):603-6. PMID:21117488 [PubMed - indexed for MEDLINE] Flego A1, Herbert J1, Waters E2, Gibbs L2, Swinburn B3, Reynolds J4, Moodie M1. Jamie's Ministry of Food: QuasiExperimental Evaluation of Immediate and Sustained Impacts of a Cooking SkillsProgram in Australia. PLoS One. 2014 Dec 16;9(12):e114673. doi: 10.1371/journal.pone.0114673. eCollection 2014. Gladwell Malcolm, What the Dog Saw, Penguin Books, 2009 Turid Rugaas, Calming Signals, Dogwise Publishing, 2006

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World Book of Family Medicine – European Edition 2015 Carlos Brotons MD, PhD [email protected]

21 – Prevention and Health Promotion in Clinical Practice Carlos Brotons MD, PhD, on behalf of EUROPREV (European network for prevention and health promotion in GP/FM)

Primary health care is a suitable setting for interventions to identify and reduce behavioural risks factors and recommend preventive activities (including immunisations, screening for cardiovascular risk factors and cancer, and counselling). A survey carried out in the year 2000 among 2082 GPs from eleven European countries showed that significant gaps persist between GPs' knowledge and their practice in the use of evidence-based recommendations for health promotion and disease prevention in primary care (1). To complement this GPs’ survey, and in order to explore patients’ views and beliefs on the importance of lifestyle and preventive interventions, another survey was carried out in the year 2008-2009, involving 7947 patients from 22 European countries (2). The results of this survey showed that alcohol drinkers do not see, or fail to admit, that alcohol use is a risky habit that needs to be modified. Less than one third of risky drinkers would like to receive advice concerning alcohol intake from their GPs. It seems that patients are much more conscious about the risk of tobacco, unhealthy diet or sedentary lifestyle than the risk of alcohol. Also, patients reported that they had received less advice (in a discussion initiated by GPs) for alcohol than for tobacco, diet and physical exercise. In another study done in Sweden, only 18% of patients reported that they had received advice at least in one area, with a four-fold variation between the most common type of advice (exercise in 16%) and the rarest type (alcohol in 5%) (3). The view of patients that GPs initiated a discussion on smoking in 63% of cases, eating habits (59% of cases), and physical activity (55%) shows some correlation with the views of GPs in Europe as surveyed in 2000 (1). At that time, GPs declared that they advised smokers to quit in 61 – 71% of cases, and counselled overweight and sedentary patients in 59 – 62% and 54 – 57% of cases respectively. However, in this study patients identified as risky drinkers said that their GPs had only initiated a discussion regarding their alcohol use in 42% while the 2082 doctors participating said they would advise heavy drinkers to reduce consumption in 57 – 64% of cases. Thus while patients and doctors seem to agree regarding the frequency of their discussions on smoking, healthy eating/weight and physical activity, patients seem to have a more negative viewpoint on how often doctors give advice on alcohol use. Table shows the views of patients regarding optimal interval for screening for cardiovascular risk factors and cancer and for vaccination. More than 80% of women think they should be checked for cervical cancer yearly or every two years. However, revised guidelines recommend Pap test screening every three years for women age 30 and older (4). These findings reflect overuse of Pap test screening, which is expensive for the health care system and may result in unnecessary follow-up testing and increased risk for colposcopy-associated illnesses and adverse birth outcomes, as well as distress for patients (5).

The survey also showed that 43% of women aged 30-49 thought that screening for breast cancer should be done

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World Book of Family Medicine – European Edition 2015 yearly or more often and that 30% felt that screening should take place every two years. This recommendation is a direct challenge to the strong message from massive campaigns aimed at women in some countries over the last two decades advising they undergo yearly screening starting at age 40, and this is also reflected in the results of our study. Other studies have also found that opportunistic mammography screening in excess of the recommendation is common and persists despite explicit advice about recommended screening frequency (6). Health professionals should be conversant with the recommended testing intervals for cardiovascular risk factors and for cancer screening in order to better educate patients in the judicious use of such tests. Table. Views of patients regarding the optimal interval for screening for cardiovascular risks factors and cancer, and for vaccination. How often do you think it would be appropriate to have…,% (95% CI)

Not at all

I don't know

Yearly or more often

Every 2 years

Every 3 years

Less often than every 3 years

1.2%

75.1%

5.2%

1.1%

0.9%

(72.0-78.0)

(4.3-6.3)

(0.7-1.7)

(0.5-1.6)

Blood pressure check (n=5085) 1

(0.8-1.7)

15.5% (13.7-19.7)

Blood sugar check (n=6865) 2

1.1% (0.8-1.6)

16.7% (14.5-19.3)

66.0% (63.3-68.7)

12.4% (10.9-13.9)

2.3% (1.7-3.0)

1.5% (1.1-2.2)

1.3%

17.5% (14.8-20.5)

62.6%

14.3%

2.7%

1.7%

(59.6-65.5)

(12.5-16.3)

(2.1-3.4)

(1.2-2.5)

Blood cholesterol check (n=5805) 3 Flu vaccination (65 years old and over) (n=928) Cervical smear test (only women) (n=4007) 4

(0.9-1.8) 14.4%

67.6%

2.0%

0.6%

0.2%

(10.9-18.7)

15.2% (11.7-19.5)

(61.1-73.5)

(1.0-3.7)

(0.2-2.4)

(0.0-1.1)

1.9%

8.5%

58.2%

23.3%

5.9%

2.2%

(1.2-2.8)

(7.1-10.3)

(54.9-61.5)

(20.8-26.0)

(4.6-7.6)

(1.6-2.9)

Mammogram (only women) (n=3650) 5 30-49 years (n=1919)

50 years or more (n=1731)

1.4% (0.7-2.8)

14.4% (12.0-17.1)

43.1% (38.9-47.4)

29.7% (26.5-33.3)

6.6% (5.0-8.7)

4.8% (3.5-6.5)

2.8%

8.2% (6.2-10.6)

41.7%

40.6%

4.5%

2.3%

(38.3-45.2)

(37.1-44.2)

(3.2-6.1)

(1.5-3.6)

(1.7-4.5)

1 Excluding patients diagnosed with high blood pressure 2 Excluding patients diagnosed with high blood glucose 3 Excluding patients diagnosed with high blood cholesterol 4 Excluding women diagnosed with cervical cancer 5 Excluding women diagnosed with breast cancer

Take home messages 

A high proportion of patients attending primary care with unhealthy lifestyles (especially risky drinkers) do not perceive the need to change their habits.



Half the patients reported not having had any discussion on healthy lifestyles with their GPs.



Patients overestimate their need to be screened for cardiovascular risk factors and for cancer.



Further studies are needed to investigate the reasons behind these perceptions so that suitable strategies may be devised to tackle them.



Health professionals should be conversant with the recommended testing intervals for cardiovascular risk factors and for screening for cancer in order to better educate patients in the judicious use of such tests.

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Original abstract http://www.woncaeurope.org/content/3851-prevention-and-health-promotion-clinical-practice-views-general-practitionerseurope

References 1. 2. 3. 4. 5. 6.

Brotons C , Björkelund C, Bulc M, Ciurana R, Godycki-Cwirko M, Jurgova E, et al. on behalf of the EUROPREV network. Prevention and health promotion in clinical practice: the views of general practitioners in Europe. Prev Med 2005; 40:595601. Brotons C, Bulc M, Sammut M , Sheehan M, da Silva Martins C M, Björkelund C, et al. Attitudes toward preventive services and lifestyle: the views of primary care patients in Europe. The EUROPREVIEW patient study. Family practice 2012; 29 (suppl. 1): i168-i176. Johansson K, Bendtsen P, Akerlind I. Advice to patients in Swedish primary care regarding alcohol and other lifestyle habits: how patients report the actions of GPs in relation to their own expectations and satisfaction with the consultation. Eur J Public Health 2005; 15: 615-20. Cervical Cytology Screening. The American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 2009; 109: 1-12. Yabroff KR, Saraiya M, Meissner HI, Haggstrom DA, Wideroff L, Yuan G, et al. Specialty Differences in Primary Care Physician Reports of Papanicolaou Test Screening Practices: A National Survey, 2006 to 2007. Ann Int Med 2009; 151: 60211. Chamot E, Charvet A, Perneger TV. Overuse of mammography during the first round of an organized breast cancer screening programme. J Eval Clin Pract 2009; 15: 620-5.

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World Book of Family Medicine – European Edition 2015 Marjan van den Akker, MD, PhD [email protected]

22 – Determinants of Multimorbidity Marjan van den Akker, MD, PhD Maastricht University, School CAPHRI, dept of Family Medicine, KU Leuven,dept of General Practice Co-authors Christiane Muth, Job FM Metsemakers, J André Knottnerus, Frank Buntinx

Introduction Multimorbidity, often defined as the co-occurrence of two or more (chronic) diseases within a patient, without an index disease being specified (1), is the rule rather than the exception in daily clinical practice. In Western countries the prevalence of multimorbidity in the general population ranges around 20-30% when the whole population was considered, and ranges between 55-98% when only older persons were included (2), with Asian studies showing similar results.

Risk Factors Associated for Multimorbidity The main risk factor for multimorbidity seems to be age: in older populations the prevalence of the most common diseases, such as heart failure and dementia, is much higher than among younger patients, resulting in frequent co-occurrence of diseases. Multimorbidity is therefore often positioned as a condition of older patients. This is confirmed when looking at relative numbers, but increasingly it is recognized, that in absolute numbers the majority of patients suffering from multimorbidity is less than 65 years of age, with Barnett et al (3) reporting just over half of the people with multimorbidity to be 65 years of age or less. Secondly, women and persons from low social classes consistently appeared to be more prone to multimorbidity across Western and Asian studies (2, 4). In a Brazilian study, Andrade et al (5) reported that somatic and mental disorders also frequently co-occur in a population sample of a developing country. The results suggest that substantial proportions of both chronic medical and psychiatric morbidities are not attributable to disorder-specific risks but rather to a few generic liability factors associated with many disorders, like lifestyle and distress. This supports the notion of general disease susceptibility (6). Thirdly, ethnic, educational and cultural differences seem to play an important role: Black Americans had significantly higher initial levels of multimorbidity relative to white Americans in a national representative sample of US adults (7). The same study by Quinones et al. showed that higher education is associated with fewer reported diseases.

Methodological Influences on Prevalence Estimates Already in the late 1990s it was recognized that many of the choices related to design of the study, definition and operationalisation of multimorbidity strongly influence the reported prevalence and incidence of multimorbidity (8). The influence of methodological decisions on the reported amount of multimorbidity is considerable. Starting with the various definitions of multimorbidity, where the minimum numbers of diseases differ (two vs three or more chronic conditions), or where multimorbidity is defined as the simultaneous presence of diseases/symptoms, cognitive and physical functional limitations, or the

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World Book of Family Medicine – European Edition 2015 unit of counting is organ systems instead of diseases. Furthermore, the number of conditions studied is of major importance for prevalence estimates: the higher the number, the higher the occurrence of multimorbidity. Apart from a disease count there are a number of validated indices, such as the Charlson Index and the Cumulative Index Rating Scale. Although some indices cover only a limited number of diseases, they all aim to weigh the presumed impact according to illness burden. As chronic conditions widely differ in terms if severity and effects on survival and functioning, the mere number of chronic conditions do not necessarily have a major impact on outcomes. We can reasonably hypothesize that disease severity, disease duration and interactions between acute and chronic conditions are probably much more important than the mere count of chronic morbidities in increasing mortality risk. On the other hand, all studies agree on the fact that persons with multiple diseases have significant medical needs, which raises issues of resource allocation, equality and prioritization (2). There is a serious distinction between data collection based on physician-diagnosed diseases (chart, paper files, EMR), administrative data, or patient self-reported diseases (questionnaires, interviews). The agreement between physiciandiagnosed and patient-reported diseases is limited. Based on availability / feasibility, data choices made should be optimally adjusted to the research question. In general, it can be stated that the more specialized the care setting the higher the prevalence of multimorbidity. Going from the general population to people in the waiting room in primary care, to a hospitalized population, the prevalence of multimorbidity is likely to increase gradually.

Future Research It has been argued that future studies must begin to investigate multimorbidity across life course, to enable the distinction between real longitudinal changes and cohort effects. Furthermore, overlooking the field, knowledge on determinants of multimorbidity is still lacking for the greater part.

Key Points Population prevalence of multimorbidity is 20-30%; with a sharp increase above 55 years; in absolute numbers of all patients with multimorbidity, more than half are over 65 years of age. Older age, female sex and lower level of education are apparent determinants of multimorbidity. Different definitions of multimorbidity and other methodological decisions have an influence on the reported multimorbidity.

Take Home Messages 

Population prevalence of multimorbidity is 20-30%; with a sharp increase above 55 years; in absolute numbers of all patients with multimorbidity more than half are older than 65 years.



Older age, female sex and lower level of education are apparent determinants of multimorbidity.



Different definitions of multimorbidity and other methodological decisions have an influence on the reported multimorbidity.

Original Abstract http://www.woncaeurope.org/content/determinants-multi-morbidity

References Full list of references is available on request from the first author. 1. Van den Akker M, Buntinx F, Knottnerus JA. Co-morbidity or multimorbidity: what's in a name? A review of literature. Eur J Gen Pract. 1996;2:65-70. 2. Marengoni A, Angelman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011;10:430-9. 3. Barnett K, Mercer S, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;379. 4. Khanam M, Streatfield P, Kabir Z, Qiu C, Cornelius C, Wahlin A. Prevalence and patterns of multimorbidity among elderly people in rural Bangladesh: a cross-sectional study. J Health Popul Nutr. 2011;29(4):406-14. 5. Andrade L, Bensenor I, Viana M, Andreoni S, Wang Y. Clustering of psychiatric and somatic illness in the general

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6. 7. 8.

population: multimorbidity and socioeconomic correlates. Braz J Med Biolog Res. 2010;43(5):483-91. Van den Akker M, Vos R, Knottnerus J. In an exploratory prospective study on multimorbidity general and disease related susceptibility could be distinguished. J Clin Epidemiol. 2006;59(9):934-9. Quinones A, Liang J, Bennett J, Xu X, Ye W. How does the trajectory of multimorbidity vary across black, white, and Mexican Americans in middle and old age? Journals of Gerontology, Series B, Psychological Sciences and Social Sciences. 2011;66(6):739-49. Van den Akker M, Buntinx F, Roos S, Knottnerus J. Problems in determining occurrence rates of multimorbidity. J Clin Epidemiol. 2001;54(7):675-9.

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World Book of Family Medicine – European Edition 2015 Radost Assenova, MD, PhD [email protected]

23 – When Chronic Care Becomes End-of-Life Care: Bridging the Gap Radost Asenova, MD, PhD Assoc Professor, Dept. General Practice, Public Health Faculty Medical University of Plovdiv, Plovdiv, Bulgaria National representative of EGPRN Chairperson of Bulgarian General Practice Society for Research and Education

Population ageing remains a global phenomenon and it is not only a triumph for society but a huge challenge for health care systems. Advances in health care have transformed our society and as a result fewer people today die of infectious diseases, and more people live longer. In addition however, more people are living longer with serious and chronic illnesses characterised by fluctuations in trajectory, uncertainty in prognoses, extended disease timelines and stress. Helping someone that is living with a chronic condition can be challenging and sometimes the transition to end-of-life care is introduced too late to be fully effective.

The Key Question Is “When Does End-of-life Care Begin?” The point at which end-of-life care begins depends on patients’ needs. End-of-life care may last a few days, or for months, or years, beginning and ending when the patient needs it. Often doctors focus on curing the disease but few have the time to explore all the wide-ranging solutions that can address symptoms and restore people to normal life as far as possible. The current evidence suggests various gaps in care, as reported by patients, their families, GPs and other health care providers. Identified gaps in the end-of-life care include problems in areas such as:    

patient’s quality of life quality of care physical or psychological distress of caregivers cost-effectiveness of care.

Quality of care incorporates a great variety of aspects related to structure and process of care such as:  

physical aspects of care which hide many underwater stones in the management of pain, other symptoms and side-effects of treatment psychological and psychiatric aspects of care which involve trained professionals working as a team and special attention given to delivering bad news



social needs, spiritual, religious and existential aspects of care which are often underestimated



not respecting cultural preferences of patients and family



disregard for the end-of-life concerns, hopes, fears, and expectations of the imminently dying patients



and finally, key ethical and legal issues for terminal patients

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World Book of Family Medicine – European Edition 2015 A great variety of initiatives are needed to bridge the gaps in the current practices of care and achieve a better quality of life. Providers who care for chronically ill patients should be supported with evidence-based guidelines, specialty expertise, and information systems. This vast subject would require a much more comprehensive approach beyond the health care system as it concerns other areas such as employment and the environment - “health in all policies”. Another consideration is “What are the patient’s desires and wishes?” There is a need for an approach that focuses on the individual who has specific needs related to provision of prolonged and continuous care. These needs can be: 

medical; with regard to pain control and prevention of complications, etc.



psychological; associated with the need for information or emotional support



social aid in patients’ daily life and involvement in the community

 spiritual; searching for a meaning. All these needs relate to the organisation of healthcare, accessibility of services, and coordination between care settings. The key being “Patient gets the right care at the right time in the right setting by the right health care providers.” In the search for effective and efficient solutions for the management of long term care, scientists are developing different programs. The Chronic Care Model by Ed Wagner describes the necessary components for a delivery system that encourages and sustains productive interactions between patients and providers. Improving Chronic Illness Care’s Chronic Care Model brings together the best in research and practice for chronic illness care interventions. The KCE report from Belgium in 2012 proposed a draft of an optimal-idealised-system, with the characteristics for the optimal management of chronic diseases that is needs-based, personalized, goal-oriented, planned and services are provided in a high quality, efficient, sustainable, accessible, culturally competent and patient empowering manner in the least complex environment that is clinically appropriate. Palliative care offers an alternative perspective. Palliative care is a new, supportive, compassionate and integrative approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain, and other problems. Palliative care can be provided in hospitals, nursing homes, outpatient palliative care clinics, other specialized clinics, or at home. Palliative care teams help patients manage their new circumstances and relieve some of the physical and mental stress of internal illness. Ultimately, palliative care helps individuals live as well as possible for as long as possible. It is focused on timely identification of patients in need of palliative and end-of life care, assessing and agreeing how to meet people’s needs and preferences, timely referral to palliative care experts, collaboration between patients, family and the medical team, the use of guidelines and appropriate working procedures, and knowledge of palliative care and symptom management on the clinical wards using advanced care planning, and delivering high quality services. The end of a person’s life can be one of the most important moments in that life. Meeting end-of-life care gives rise to ethical issues. Voluntary euthanasia and physician-assisted suicide bring about many ethical issues regarding a patient’s death and have been the focus of great controversy in recent years. Some physicians claim that euthanasia is a rational choice for competent patients who wish to die to escape unbearable suffering. Others feel that aiding in the patient’s death goes against a physician’s duty to preserve life that is morally unacceptable. Some forms of voluntary euthanasia are legal in Belgium, Luxembourg, the Netherlands, Switzerland, and some states in the USA. Primary health care, provided by GPs, is to a great extent the cornerstone of eliminating some of the gaps previously mentioned. High quality training for family doctors is vital to ensure the delivery of quality chronic disease management and a smooth transition to palliative care. Patient-centred care is an option to help patients and families in various ways. Good doctor–patient communication leads to various positive aspects both for patients as increased satisfaction, better health outcomes, improved understanding, increased adherence to treatment and for doctors - decreased job distress and less emotional stress and burnout.

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Take Home Messages 

Proactive and holistic thinking



Attention to patient and family as unit of care; patient-centred approach



Education and support for the patient and family, and continuing medical education for care providers



Effective communication



Interdisciplinary team approach

Original Abstract http://www.woncaeurope.org/content/4325-when-chronic-care-becomes-end-life-care-bridging-gap

Reference        

Ambigga KS, Ramli AS,Suthahar A,Tauhid N,Clearihan L, Browning C. Bridging the gap in ageing: Translating policies into practice in Malaysian Primary Care. Asia Pac Fam Med 2011;10(1):2. Effiong A, Effiong AI. Palliative care for the management of chronic illness: a systematic review study protocol. BMJ Open 2012;2:e000899 doi:10.1136/bmjopen-2012-000899 Foreva G, Asenova R, Semergjieva M. Follow-up of patients needing palliative care in general practice. Progress in Palliative Care 2014, DOI: http://dx.doi.org/10.1179/1743291X13Y.0000000072. Foreva G, Assenova R. Hidden Patients: The Relatives of Patients in Need of Palliative Care. Journal of Palliative Medicine 2014,17(1):56-61. doi:10.1089/jpm.2013.0333. http://www.goldstandardsframework.org.uk http://www.improvingchroniccare.org/; available 2014 https://kce.fgov.be/; KCE Report 109C 2012. Health Services Research. Organisation of Care for Chronic Patient in Belgium: Development of a position paper; available 2014 O'Grady EL, VanGraafeiland B. Bridging the Gap in Care for Children Through the Clinical Nurse Leader. Pediatr Nurs. 2012;38(3):155-158, 167.

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World Book of Family Medicine – European Edition 2015 Matie Obazee, FWACP(GP), FMCGP, MBA [email protected]

24 – What is Universal in Primary Care? Challenges for North/South Co-operation. Ehimatie M. Obazee FWACP(GP); FMCGP; MBA. Medical Director Echos Hospital Ltd, Benin City, Nigeria. Visiting Consultant, Department of. Family Medicine, University of Benin Teaching Hospital, Benin City. Nigeria Co-author Michael Kidd AM Executive Dean Faculty of Medicine, Nursing and Health Sciences, Flinders University, Australia President World Organization of Family Doctors (WONCA)

Introduction A cursory examination of the way Primary Care is practised in the Northern and the Southern hemispheres gives the impression of vast differences in orientation, settings and operations. With the advent of the global focus on Primary Health Care heralded by the Alma Mata declaration of 1978, the focus of Primary Health Care in the South was predominantly Community oriented. Emphasis was on disease prevention through immunization, provision of water and environmental hygiene (1). The operation was driven by Community Health Extension Workers and other Physician assistant personnel. On the other hand, in the North, the orientation has traditionally been based on physician-led individual person-centred care often with strong Private Public Partnership. Over the years, there has been a convergence in the approach to Primary Care with more integration of both models to varying degrees. However, differences still exists in broad terms. The apparent differences often give the impression that there is nothing in common in Primary Care between the North and South. The impression is further accentuated by the vast array of ethnic, cultural, social, economic and technological diversity in which Primary Care operates in both settings. The apparent differences give the impression of a parallel paradigm with no meeting point, nothing in common and nothing to learn from each other. This is misleading.

What is Universal? Within the midst of the array of ethnic, cultural, social and economic diversity is the universal cord that ties us all together – the humanity in us. At the most basic level, man’s needs are the same irrespective of the circumstances, location or situation of our birth – the need for self-preservation, safety and security, love and self esteem. Primary Care is at the heart of the most basic of these needs - the instinct for self preservation. Forging alliances with people and their families to promote optimum health, prevent disease, and when necessary make prompt accurate diagnosis and implement /coordinate effective care to our patients in the most dignified manner possible. The basic elements of Primary Care - accessibility, comprehensiveness, continuity and coordination apply universally (3). The attributes of good primary care - compassion, patience, love of people, love of communication and care are universally demanded and appreciated(4). Perhaps the strongest articulation of the universality of the quest for Primary Care is that of Margaret Chan, the Director General of WHO in her introductory remarks to the World Health Assembly 2008 World Health Report:

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World Book of Family Medicine – European Edition 2015 "A primary care approach is the most efficient, fair, and cost effective way to organise a health system. It can prevent much of the disease burden, and it can also prevent people with minor complaints from flooding the emergency wards of hospitals. Decades of experience tell us that primary health care produces better outcomes, at lower costs and with higher user satisfaction" (5) The entire report titled "Primary Care; Now More Than Ever" underscores the urgency of concerted universal efforts to give thought to rekindling attention to the development and sustenance of Primary Care (6). However, Primary Care has many different faces, depending on the context and geographical location where it is practised. Whereas in one location it may be normal to perform a surgical procedure for appendicitis on the kitchen table, it is highly irregular to perform the same procedure in another place. Though both doctors work in Primary Care, their task description is very different – modified by several factors. The moderating factors include the economic environment, the level of social and technological development and the effectiveness of the Health Systems in place. Even within Regions, there are differences. Health Systems in the United States and Canada for example are quite different from those in Brazil or Cuba. These factors are dynamic and undergoing continuous evolution. This has resulted in evolutionary continuum with the North predominantly at one end and the South at the other in different fronts. These factors of socio-economic and cultural realities impart on how Primary Care is implemented. The implementation of Primary Care is in the context and place where it is practised. Therefore, there is no such thing as a unique form of Family Doctor.

North/South Co-operation The peculiarity of the circumstances and situations under which Primary Care is practised from North to South offers unique challenges to the practitioner. The mastery of these challenges builds valuable experience for the practitioner whether practising in the North or the South. The experiences in a geopolitical zone at a point in time are potential sources for learning for others. The examples of Brazil and Cuba's models of Primary care are veritable examples which offer lessons for Countries in both the North and South. Most of the time, North-South co-operation is seen as a one – directional way of assistance. But as described above, the time and place of delivering Primary Care are so different, that there is no real mirror of the circumstances. Therefore, bi-directional co-operation in which experience are shared between the North and South is what is needed. The vital questions should be: What can each of us contribute to each other? What can the North learn from the South and vice versa? There is a lot we can learn from each other - From National Health Systems, how Primary Care is delivered at practice level to epidemiological disease prevalence, pattern and treatment.

Challenges Implementing such bi-directional co-operation has its challenges: Living in a world where Malaria and Ebola are prevalent is quite different from a world with largely lifestyle problems as challenges. Hypertension is a Northern problem, Dengue and Malaria are Southern problems. Cancer and Diabetes Type 2 are ubiquitous; but one has to live long enough to get them. To add to the complexity, in the dynamic societal evolution and globalization, what was exclusively a Northern problem yesterday is gradually becoming a universal problem today and vice versa. This is why co-operation is inevitable.

Take home messages 

Primary care offers the opportunity to forge an alliance with people and their families to promote optimum health, prevent disease, and when necessary make prompt accurate diagnosis and ensure effective care to our patients in the most dignified manner possible.



The peculiarity of the circumstances and situations under which primary care is practised in both the North and in the South offers unique challenges to the health care practitioner.



We need bi-directional approaches and co-operation, in which experiences are shared between the South and the North.



The best way to co-operate is to learn from one another – and that is why WONCA is so important. It offers the opportunity through its Conferences and other activities to exchange experience and ideas. 80

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Original abstract http://www.woncaeurope.org/content/291-what-universal-primary-care-challenges-northsouth-co-operation

References 1. 2. 3. 4. 5. 6.

World Health Organisation: Declaration of Alma-Ata International Conference on Primary Health Care. www.who.int/publications/almaata_declaration-en.pdf World Health Organization: Main Terminology - Primary Health Care. Http:// www.euro.who.int/en/what-we-do/healthssytems/primary-health-care/main-terms-used. WHO: The World Health Report 2008: Primary Care, Now More Than Ever. http//www.who.int.whr08-en.pdf. WHO: Director-General's Speeches. Primary Care :Now More Than Ever. who.int/dg/speeches/2008/30081014. Molly Edmonds: Health Systems Around the World. People.howstuffworks.com/10-health-care-systems.htm. Wonca in brief. Global Family Doctor. globalfamilydoctor.com/aboutwonca/brief.aspx.

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World Book of Family Medicine – European Edition 2015 Theo Schofield, OBE FRCP FRCGP [email protected]

25 – The New Consultation: The Doctor in the Electronic Age Theo Schofield OBE FRCP FRCGP, retired Lecturer and Fellow of ETHOX, Department of Primary Care University of Oxford. Co-author Peter Havelock, retired Associate Advisor in General Practice, Oxford Deanery.

The New Consultation: developing doctor-patient communication, (Pendleton et al 2003), and it’s predecessor The Consultation: an approach to learning and teaching (Pendleton et al 1984) both described: 

the current literature on Doctor Patient communication



the ideas, concerns and expectations that patients bring to their consultation



the opportunity that each consultation has to develop the patient’s understanding



the potential to develop the relationship between the doctor and patient over time. Based on this “Cycle of Care” we were able to describe Tasks to be achieved in the consultation, which in summary are: Understanding the patient’s problem Understanding the patient Sharing understanding Sharing decisions Sharing responsibility, and

Developing a relationship that helps to achieve the other tasks. Are these still relevant in “The Electronic Age” characterized by the emphasis on Evidence Based Medicine and Shared Decision Making, by new technologies, and by developments in health care systems? Evidence based medicine aims to improve the quality of the evidence on which clinical decisions can be based. However most evidence is derived from populations, while the clinician is dealing with an individual patient, and that the approach can generate a “right” answer, with which the clinician, and in turn the patient, is encouraged to comply. Shared decision making, or Evidence Based Patient Choice (Elwyn et al 1999), responds to these criticisms by an approach where clinicians and patients make decisions together using the best possible evidence. This involves presenting the evidence about diagnosis, options for treatment and it’s benefits and harms and uncertainties, in ways that are fully comprehensible to patients, and encourages and enables patients to make choices about their own care. There is evidence that shared decision making can produce better informed patients who are less passive, who adhere better to treatment, and who sometimes make more conservative decisions about treatment. There is strong professional and institutional support for the implementation of shared decision making. (The Salzburg Declaration 2010). Another major technological change is the almost universal presence of the Computer in the Consulting Room. This 82

World Book of Family Medicine – European Edition 2015 has transformed record keeping, particularly in primary care. They can provide structured records and templates for the management of chronic conditions, for results and for screening and prevention. The patient’s record can be shared with other team members, and across sites, and in some settings patients can access their own records, and become more involved in their own care. Computerization of the consultation can also bring problems. It can interfere with maintaining eye contact with the patient, and can influence the doctor’s agenda to be more structured and task orientated in response to the templates and prompts of the computer. Bensing et al in 2006 found that in two sets of recorded consultations with patients with hypertension separated by 10 years, the technical quality of care by the doctors improved, while the patients spoke less, asked fewer questions, and expressed fewer concerns and worries. She speculated that this reflected the shift towards more evidence based protocol driven care, as well as the influence of the computer in the room. Computers also allow doctors and patients to access information, guidelines and decision aids either in the consultation, or for patients to consider afterwards. This can also include examples of patient experiences on sites such as Healthtalk (Ziebland et al 2013). The telephone is being used increasingly as a means of communication with patients in many settings. It can improve access and follow up, it can be convenient for patients, and can be a more efficient use of doctors’ time. On the other hand a telephone consultation does not involve face to face contact, omits visual cues and physical examination, and both the doctor and the patient may feel that it was a “second best” and riskier encounter. Other modes of communication such as Email, Web sites and Social Media are less well established but offer opportunities for innovation, as does self-recording and monitoring using smart phones. All have the potential to help patients become better informed and more in control of their own health care. However it is face to face contact that builds mutual understanding and trust between doctor and patient. Continuity of Personal Care is valued by many patients, particularly those that are older, have long term medical conditions or psychological conditions. Supporters of personal continuity argue that personal continuity leads to increased patient satisfaction, more trust, and better care (Gray DP et al 2013). However, in the United Kingdom the health care system has recently given greater weight to accessibility, which is also valued by patients. Changes in the contract with general practitioners, and increased shift working in hospitals, have made the delivery of personal continuity more difficult. Per Fugelli in his James Mackenzie Lecture in 2001 defined Trust as the individual’s belief that the sincerity, benevolence and truthfulness of others can be relied on, and that trust often implies a transfer of power to a person, or to a system, to act on one’s behalf, in one’s best interest. He described personal trust as the trust you have in an individual, such as your doctor, and social trust as trust in societal institutions such as the government or health care institution. He went on to describe the influence that trust, or the lack of it, has on the process of the consultation.

Take Home Messages 

Understanding the patient, their problems and their perspective remains an essential task in an effective consultation.



Shared Decision Making can enable patients and improve their care.



New technologies offer new opportunities for communication, but should not be a substitute for face to face contact.



It is essential that we maintain the trust of patients in their doctor, the medical profession and the health care system.

Original Abstract http://www.woncaeurope.org/content/466-new-consultation-doctor-electronic-age

References   

Pendleton D, Schofield T, Tate P and Havelock P. 2003. The New Consultation. OUP .Oxford. Pendleton D, Schofield T, Tate P and Havelock P. 1984. The Consultation: an approach to learning and teaching OUP. Oxford. Elwyn G, Edwards A and Kinnersley P. Shared decision making in primary care: the neglected second half of the

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    

consultation. BJGP 1999; 49 :477-482. The Salzburg statement on shared decision making BMJ 2011;342: d1745. Ziebland, S Coulter A Calabrese J Locock L (Eds) (2013) Understanding and Using Health Experiences: improving patient care. OUP. Oxford Bensing JM et al. Shifts in Doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients. BMC Family Practice 2006; 7: 62 Gray DP, White E and Evans P. The importance of continuity of care. BJGP 201464:446. Fugelli P. Trust - in general practice. BJGP 2001;51: 575-579.

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World Book of Family Medicine – European Edition 2015 Jaime Correia de Sousa, MD, PhD [email protected]

26 – How to Deliver a Successful Learning Package for Family Medicine Trainees? Jaime Correia de Sousa, MD, PhD Community Health, School of Health Sciences, University of Minho, Portugal

Like most learners, FM trainees are eager to learn to become competent professionals. It is the task of tutors and course organisers to guarantee the quality of learning. In order to be successful, learning programmes require a certain number of features. Family Medicine has been in the front line of innovation in designing learning and teaching programmes to fit the objectives and learning needs of trainees (1). Furthermore, it has published guidance and developed several courses to allow the development of teaching skills of tutors and teachers in family medicine (2,3).

What Makes a Teaching Programme Successful? This text will review some of the characteristics of a teaching package that can include in-person learning, such as small group work modules combined with distance learning, mostly using problem based learning and integrating practical work in a real primary care setting. Learning objectives and content can be adapted to work with small groups, individual learning or one-to-one teaching in a residency programme. We will consider the six key features that make such a comprehensive programme effective.

Content In most countries, there is already a good syllabus defining the content of learning and teaching in the training phase (4). In the planning stage of each learning package, teachers have to define very clearly the purpose of the module that should be based in the assessment of the training needs, the skills and knowledge deficits of students and the learning objectives (5). The objectives have to be written in a clear way as measurable statements of what participants should know or be able to do. Ideally, the specific training needs of each trainee or group of trainees should be evaluated previously to the design of the programme, so that the teaching and learning package is tailored to the participants’ knowledge or skills gaps (5,6).

The Human Factor Training involves different people who agree to participate and need to be aware of their roles and tasks. Trainer and trainee have to be capable to build and maintain a continuing relationship. They should also be able to involve the practice nurses and staff and to obtain the consent from patients, who should be clearly informed of their rights and assured that their voluntary participation is important for the teaching programme and that any inconvenience should be minimised.

The Environment 85

World Book of Family Medicine – European Edition 2015 Teaching and learning is facilitated by an adequate environment. Premises for group work should allow a distribution of seats so that all participants and the speaker can face each other. If a group sits in a circle without a table, communication is likely to be easier. Designing web based teaching requires certain skills and the support of a good technical team. In a teaching practice, the premises have to meet certain requirements such as a minimum number of consulting rooms and areas for meetings and presentations. Besides the normal clinical tools there should be equipment specifically dedicated for teaching, such as a fast internet access, data-show and screen, flip charts, and video cameras.

Types of Learning Other important features that need attention are the types of learning required with relation to different aspects of education. Types of learning fall into three categories. The first one consists of the knowledge of specific facts, patterns, and concepts. The second category includes the skills that require practical abilities, manual skills measured in speed and / or precision, clinical reasoning and problem solving aptitudes. The third one contains the attitudes, realising feelings, values, and motivation (5). Learning also requires adaptation of the program to individual trainees as people have different individual learning styles. Some persons learn quickly by listening, some others need to complete listening by reading and memorising; others have to repeat and correct the skill until they know it. This requires the tutor to take into account the trainee's preferred learning style and to consider the trainee’s learning needs.

Communication Good communication is essential for effective teaching and learning. Tutor and trainee should develop an adequate communication mode. This requires frequent interaction aimed at clarification, problem solving and course correction. Adult learning though, is a process that requires independent learning and the role of the tutor is more of a facilitator and organiser coaching the trainee through the learning process. Qualities such as openness, networking, and proactive communication are important ingredients in the process of personal and organisational change (7).

Assessment Assessment is important because it drives learning, allows measures of individual and programmatic progress and assures the public that providers are competent. It is fundamental to outcomes or competency-based education (8). Assessment methods have to be adapted to the type of learning. Common methods of assessment such as multiple choice questions, simulation tests, and objective structured clinical examinations (OSCEs) target the lowest levels of the learning pyramid (7,8), while work based methods of assessment target the highest level of the pyramid and collect information about doctors’ performance in their normal practice and should be preferred in a more comprehensive teaching program.

Miller’s Pyramid of Competence. (8)

Conclusion Delivering a successful learning package for FM trainees requires a certain number of skills. Family Medicine teachers and tutors should be aware of this and undergo some of the available training programmes in order to master the 86

World Book of Family Medicine – European Edition 2015 basic features of adult education. This will be a key element in assuring the quality of future family physicians.

Take Home Messages 

Learning is a process that you have to learn.



Teaching is a skill that you have to learn and train.

Original Abstract http://www.woncaeurope.org/content/11-w-teaching-science-learning-care-how-deliver-effective-learning-package-gp-trainees

References 1. 2. 3. 4. 5. 6. 7. 8.

Heyrman J: EURACT Educational Agenda. Leuven: European Academy of Teachers in General Practice EURACT; 2005. Guldal D, Windak A, Maagaard R, Allen J, Kjaer NK. Educational expectations of GP trainers. A EURACT needs analysis. Eur J Gen Pract. 2012 Dec;18(4):233-7. doi: 10.3109/13814788.2012.712958. Epub 2012 Aug 31. Bulc M, Švab I, Radi S, Correia de Sousa J, Yaphe J. Faculty development for teachers of family medicine in Europe: reflections on 16 years' experience with the international Bled course'. Eur J Gen Pract 2009; 15: 69–73. General Medical Council The Trainee Doctor. Foundation and specialty, including GP training. General Medical Council, London; 2011. Northwest Center for Public Health Practice at the University of Washington School of Public Health. Effective Adult Learning. A Toolkit for Teaching Adults. University of Washington; 2014. Tomasik T, Windak A, Domagala A, Dubas K, Sumskas L, Rosinski J. An evaluation of family physicians' educational needs and experiences in health promotion and disease prevention in Poland and Lithuania--a qualitative study. BMC Fam Pract. 2011 Mar 25;12:13. doi: 10.1186/1471-2296-12-13. ABC of Learning and Teaching in Medicine. Peter Cantillon, Linda Hutchinson, Diana Wood Editors. London, BMJ Publishing Group, 2003. Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990 Sep;65(9 Suppl):S63-7.

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World Book of Family Medicine – European Edition 2015 Filippo Zizzo MD, Psych. [email protected]

27 – The Integration of Mental Health into Primary Care: International Perspectives Filippo Zizzo MD, Psych. Psychiatry lecturer at the General Practice Training School, Milan Bicocca University, Head of Scientific Medical Society SIICP

According to an evaluation in 2012, approximately 38% (1) of the European population suffer from a mental disorder at some time in their life. The WHO predicts that by 2020, significant psychiatric disorders will make a major contribution to the burden of disability and suicide (2)(3). This is even more pertinent with regard to the current economic crisis and the consequent reduction in resources and services. The message delivered to European nations at the Helsinki Conference of 2005 was that there is no health without mental health (3). Nine years later, one wonders if European states have kept their commitment to promote mental health policies with respect to public health, adoption of a life course approach targeting all age groups, making structural changes, community transformation and respect for human and civil rights of people with mental disabilities. If they had, perhaps today’s outcomes may have been different. In recent years, the international economic crisis has had an important psychosocial impact on individuals and families through the reduction of available resources. It has resulted in increasing social marginalization, unemployment and higher risk of exposure of the individual to stressful life situations, with negative repercussions through the increased risk of developing psychiatric disorders and by making treatment and recovery more difficult. In high income countries there remains a lack of social inclusion for those people with mental health problems including a fragmentation of family and social structures, poor housing, lack of employment opportunities and loss of spiritual framework. Against this background; 

Family Physicians are in a position to provide leadership in the health care system (5)

 it is important that this role is supported by national governments. Family Physicians should be carefully consulted before the development and implementation of new policies and processes in order to achieve the goal of health care cost containment and improvement in the management of mild and moderate psychiatric disorders, in order to avoid the stigmatization of mental health patients with all the negative consequences that this may carry. Family Physicians must have leadership roles in managing the delivery of health services because the Family Physician is one of the medical professionals best placed to demonstrate the full range of qualities necessary to drive change including; (6) trust and doctor-patient relationship, expertise in diagnosis and prognosis, expertise in complex decisionmaking process, the beginnings of a multidisciplinary approach to health care, professionalism, leadership and management skills in delivering comprehensive primary health care to large populations and skills in the training of medical students and doctors. In the early 2000s, care delivery to patients with mental health difficulties was driven through a lens of ethics and morals (7). Today the choice is not only based on these ideals but also on the wise use of 88

World Book of Family Medicine – European Edition 2015 limited economic resources to deliver quality interventions with a reduction in health care costs. The vision that I’m proposing, could be interpreted as reductionist but it is better at maintaining quality of care and treatment interventions ethically whilst reducing costs. To achieve this goal, Family Physicians need to become more skilled in the foundations of psychiatric diagnosis and therapy, not to become pseudo-psychiatrists but to play a pivotal function in delivering mental health services to a broader range of the primary care population. By adopting this suggested approach, the role of the Family Physician becomes the constant filter and support at the primary/secondary care intersection. We might say that there is nothing new under the sun. From my point of view there is a great difference between the former vision and the current situation. In the 1980s there was a simple proposal designed to streamline the psychiatrist’s work, making him/her responsible for interventions for the most severe and high-risk cases. The current economic stagnation dictates that there should be less waste and demands that the majority of interventions are delivered in primary care (8). Moreover, it has broadened the horizon to a world of "emerging needs" of mental health for primary care including adolescents and young people who require early intervention, the elderly, people suffering from common emotional disorders or with complex co-morbid somatic conditions and a whole population who attend family practice as the first port of call when faced with medical needs. Alongside the responsibility of delivering more treatment for newly presenting mental health problems, Family Physicians are also expected to sustain the goal of a more inclusive society by supporting the reintegration of patients with severe mental disorders. Family Physicians are called upon to promote societies’ ability to understand and tolerate the complexity of individuals and the variety of different ways of being in the world. They are also expected to avoid the temptation to make superficial changes by evading the right but difficult decisions and ignore the evidence base for political expediency and ‘short-termism’ or by merely attending to the risk associated with mental suffering and disorder. I would like to propose the following goals: Mid- term goals: A reduction in the numbers of people with mental health problems followed up by secondary care mental health services An increase in the number of patients with mental health problems managed by Family Physicians More appropriate use of the resources offered by psychiatrists in Secondary Care More rational use of nursing resources to address mental health problems Long- term goals: An improvement in the quality of interventions offered in mental distress Evidence based and appropriate consultations Evidence based clinical and therapeutic interventions Evidence based nursing interventions A decrease in hospital admissions A decrease in relapse rates Efficient management of resources In my view this is the future challenge for the Family Physician who, as a result of the nature of the role, deliver assessment and treatment to large numbers of the population within a defined geographical area, and in a broader social context, informed by the Family Physician’s depth of knowledge of the family and social contexts of his/her individual patients. Therefore, the Family Physician remains the pivotal figure of future health systems.

Take Home Messages 

Family Physicians encounter covert and sub-clinical psychiatric disorders



Family Physicians manage psychiatric disorders with reduced costs



The stigma related to mental disorder is decreased in the general practice context



Family Physicians are in a unique position to provide comprehensive management of the patient's mental and physical disorders



Family Physicians also implement social interventions for their patients

Original Abstract 89

World Book of Family Medicine – European Edition 2015 http://www.woncaeurope.org/content/cw18-integration-mental-health-primary-care-international-perspectives

References 1. 2. 3. 4. 5. 6. 7. 8.

Wittchen, H.-U. The size and burden of mental health in Europe. Israel Journal of Psychiatry and Related Sciences, 49(1), 66. 2012. McBain R., Salhi C, Morris JE, Salomon JA, Betancourt TS. Disease burden and mental health system capacity: WHO Atlas study of 117 low- and middle-income countries. Br J Psychiatry. 2012 Dec;201(6):444-50. Joseph G.Froerera, Michael Penneb, Michael Pembertonb, Ralph Folsomb. Substance abuse treatment need among older adults in 2020: the impact of the aging baby-boom cohort. Drug and Alcohol Dependence Volume 69, Issue 2, 1 March 2003, Pages 127・ 135. http://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdf. https://ama.com.au/media/unique-pivotal-role-doctors-australian-health-system Charles Watters. Emerging paradigms in the mental health care of refugees Social Science & Medicine, Volume 52, Issue 11, Pages 1709-1718.2013. Gabriel, M.D. Ivbijaro (Editor) - Companion to Primary Care Mental Health Paperback ・August 12, 2012. Weinstein and al.-Cost-effectiveness in Health and Medicine. Jama October 1996, vol.276,n.15.

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World Book of Family Medicine – European Edition 2015 Floris A. van de Laar, MD, PhD [email protected]

28 – WONCA and the Cochrane Primary Health Care Field: opportunities for a synergetic collaboration Floris A. van de Laar, MD, PhD

Dept. of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

Co-authors Caroline Roos, MA, Tom Fahey, MD Bruce Arroll MBChB, PhD, FRNZCGP Elaine Gurr Chair of General Practice and Primary Health Care Director of the Goodfellow Unit, Department of General Practice and Primary Health Care, University of Auckland

The Cochrane Collaboration is a global independent network of more than 31,000 dedicated people from over 120 countries. It constitutes an equal partnership between health practitioners, researchers, health care providers and patient advocates. Its mission is to promote evidence-informed health decision-making by preparing, updating, and promoting the accessibility of Cochrane Reviews, published online in the Cochrane Database of Systematic Reviews, part of The Cochrane Library (www.thecochranelibrary.com ). Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are the highest standard in evidence-based health care. The abstracts and plain language summaries of all Cochrane Reviews are also freely available on Cochrane Summaries (http://summaries.cochrane.org/ ), thus ensuring equal accessibility to anyone interested in evidence informed health care. In January 2011, the World Health Organization (WHO) awarded Cochrane a seat on the World Health Assembly, the decision-making body of the WHO. This provides Cochrane an opportunity to promote evidence-based health care at the highest levels of international health care policy-setting.

The Cochrane Primary Health Care Field (CPHCF) and its Achievements The Cochrane Collaboration (www.cochrane.org ) is organised by ‘entities’ called ‘groups’ or ‘fields’. Primary Health Care became the first registered field in October 1993. While the Cochrane Review Groups focus on production and promotion of Cochrane Reviews, Fields advocate the representation of certain interests in the Cochrane Reviews (for example a focus on setting, e.g. primary care, or patient groups, e.g. children). Furthermore, fields promote and enhance dissemination and implementation of evidence from systematic reviews in the area they represent. Thus, the CPHCF aims to ensure that the primary care perspectives are adequately represented within the Cochrane Collaboration. Moreover, the field promotes and stimulates the development of Cochrane reviews which are more relevant and accessible to primary care (Van de Laar 2007). Means to achieve these goals are, for example: introducing, supporting or linking primary care peer reviewers, or authors with Field-relevant expertise to Review Groups editors. In addition, the CPHCF tags existing reviews and review-protocols with ICPC-codes in order to make them more accessible to workers in primary care. This enables the products of the Collaboration to be accepted and adopted into practice. We have developed two important ‘tools’ to assist us achieve our goals. Firstly, we have created the concept of PEARLS (Practical Evidence About Real Life Situations) which are very concise summaries 91

World Book of Family Medicine – European Edition 2015 of (Cochrane) reviews focusing on one Clinical question for direct implementation in practice (Arroll 2011). PEARLS are disseminated through the CPHCF website and Newsletter, The Cochrane Library, the WONCA website and the website of the New Zealand Guidelines Group. PEARLS have also been published in the Dutch Journals of Huisarts en Wetenschap and Modern Medicine and also at conference presentations. Furthermore, we have developed the website www.cochranegetinvolved.org in which we welcome new collaborators in primary care research. Accordingly, this network is integrated into the formal Cochrane (‘Archie) network and enhances (future) collaboration with primary care research and practice. The current focus is to expand this network and link it to the activities of the various Cochrane Review Groups. Another spearhead of the CPHCF is the development of a register of studies on the development, validation and impact of Clinical Predication Rules in primary care. This project is coordinated by the Dublin branch of the CPHCF and is supported by the HRB Centre for Primary Care Research (www.hrbcentreprimarycare.ie ). So far, a register of over 700 CPRs have been identified. A reproducible search strategy to identify relevant CPRs has been developed that is enabling regular updating of the register. A searchable, web-based register is being developed and would form part of the Cochrane Primary Health Care Field activity. Other developments include assessment of CPRs in relation to their use in clinical practice guidelines, and a systematic review of randomized trials that assess the impact of CPRs in clinical practice in primary care.

Global Family Medicine and PHCF WONCA and the Cochrane Collaboration share many important objectives. Both WONCA and the CPHCF aim to foster high standards of care in general practice. With this in mind, the Cochrane Collaboration produces high quality and accessible systematic reviews for the promotion of evidence –informed health decision making. Both organizations aim to promote health equity. Cochrane strives to achieve this by making the vast amounts of evidence generated through research useful and available to everyone (both practitioners and patients) interested in human health care. In addition, both WONCA and the CPHCF are academic initiatives which aim to collect, collate and disseminate information concerning the research aspects of general practice. And finally, both WONCA and Cochrane provide a forum for exchange of knowledge in the field of health and medical care. WONCA has already important, established links with the Cochrane Collaboration. Cochrane output such as the Cochrane Library and PEARLS from the CPHCF are incorporated at the WONCA World website as important resources for general practitioners. Cochrane is also represented in WONCA through many individual members. We sincerely hope that Cochrane and WONCA will continue to collaborate in the promotion of evidence-based primary care.

Is Cochrane Helpful in Everyday Practice? For some colleagues The Cochrane Collaboration may seem an academic initiative with only a distant association to every day practice. We believe that the opposite is true (Fahey 2013). Firstly, an efficient way in applying Evidencebased principles for your patients is searching, reading and using systematic reviews. Compared to primary studies, the information-density that comes from systematic reviews is enormous. The Cochrane systematic review aims to reduce publication bias. Moreover, the latter’s structured format makes them easily accessible for readers whore are interested in part of the information only. And for those who like to cherry pick, there are many easy-to-read structured summaries available through the Cochrane summaries website, in particular for those primary care people who wish to receive the PEARLS that are distributed through the Primary Care Field. So do not hesitate and subscribe for the Field on www.cochraneprimarycare.org .

Take Home Messages 

The Cochrane Collaboration publishes Systematic Reviews in order to support evidence based decision making in Health Care



The Primary Care Health Care Field is the entity within Cochrane that represents family medicine and primary care in the Collaboration and vice versa



The Field produces PEARLS which are concise and easy-to-read abstracts of Cochrane reviews aiming at specific clinical questions



WONCA and Cochrane share many important values and further future cooperation between the primary care field and WONCA seems promising 92

World Book of Family Medicine – European Edition 2015

Original Abstract http://www.woncaeurope.org/content/cochrane-primary-health-care-field-introduction-systematic-reviews-and-cochrane-primary

References   

Arroll, B. (2011). "Getting clinical answers in 1 sentence." Ann.Fam.Med. 9(1): 86. Fahey, T., Smith SM, van de Laar, F., Kenealy, T, Arroll, B. (2013). "Cochrane reviews: relevant more than ever." British Journal of General Practice 63(606): 10. Van de Laar, F. A., T. Kenealy, et al. (2007). "Cochrane Primary Health Care Field. About The Cochrane Collaboration (Fields)." Cochrane Database Syst Rev(3): CE000051.

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World Book of Family Medicine – European Edition 2015 Sietse Wieringa, MD [email protected]

29 – Do you Understand how Your Health System Works? From Beveridge to Bismarck; a Whistle-stop Tour of European Health Systems Sietse Wieringa, GP, MSc Co-authors Luisa Pettigrew, MB ChB, MRCGP, MSc Stephanie Kumpunen, MSc Greg Irving, BMedSci, BMBS, MSc, MPH, MRCGP

As family doctors we should be thinking about how our healthcare system works and how we can shape it. We share responsibility for the distribution of limited resources not only as healthcare professionals, but also as patients and taxpaying citizens. But how much do we know about how the system works, and in particular how it is financed?

Healthcare Systems’ Goals In order to understand a healthcare system the first requirement is to think about its policy goals. The ‘final’ goals ultimately are; to improve the health of the population; to be responsive to the needs of healthcare service users and citizens; and to ensure protection among citizens from the burden of financial hardship due to healthcare payments. There are also ‘instrumental’ goals; to be transparent and accountable; to deliver high quality healthcare services; to be efficient; and to ensure equity across the healthcare system. Equity exists in several forms, such as equity in access or use of the service, equity in coverage of the type of services provided to the local population, and equity in how financial risk is redistributed. With the final and instrumental goals of a health system in mind, there are three key questions that help to determine the financing structure of a health system; (1) Where does the money come from? (2) Who collects the money? (3) How is the money spent?

Where Does the Money Come From? There are several ways to collect funds for healthcare. Options include taxation, compulsory social health insurance, voluntary private health insurance, individual medical savings accounts or out-of-pocket payments. In the case of lower income countries, funding can also come from international donations. The archetypical European models to collect funds for healthcare are the tax model, named after the English

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World Book of Family Medicine – European Edition 2015 economist William Beveridge (1879-1963), and the social health insurance model more commonly known as the Bismarck model, named after German Chancellor Otto von Bismarck (1815-1898). In 1942 Beveridge laid the foundations of the National Health Service (NHS) in the United Kingdom in which free healthcare at the point of delivery was paid through taxation collected by the government. Bismarck passed the sickness insurance law in 1883 in an effort to improve economic growth through employees’ well-being in Germany. In his model employers contributed one-third and workers two-thirds into locally managed funds that paid for medical treatment and sick pay.

In general terms, taxation and social health insurance are considered the most ‘progressive’ methods of paying for healthcare, in other words, they enable the most equitable forms of collecting and pooling funds. On the other hand out of pocket payments are ‘regressive’ or the least equitable, hitting the sickest and poorest the hardest. Every method has of course its own variants, advantages and disadvantages, as well as its ethical, moral and ideological arguments. Thinking about taxes, for example, differences can arise in whether taxes are collected directly (e.g. income tax) or indirectly (e.g. tobacco tax) or whether those who earn more should contribute a higher proportion of their earnings.

Who Collects and Redistributes the Money? The second question points to how the money is pooled and (re-)distributed. Fund pooling is the accumulation of prepaid healthcare revenues on behalf of a population and facilitates the pooling of financial risk across the population. Collection agents can either be public or private, for profit or not-for-profit. The size of pools can vary (e.g. national versus regional). If multiple pools are available a risk-adjusted re-distribution of funds according to the risk profile of the population (e.g. age, sex, etc.) covered by each pool is preferable. This, in addition to regulation, is important to prevent cherry picking of patients in competitive health insurance systems, as well as to reduce the risk of healthcare funding bodies becoming insolvent.

How Is the Money Spent? The third question explores how money is used to purchase healthcare. The range or package of services can be agreed upon in several ways, for instance by decree in the Netherlands or by negotiation in Germany. A single organisation can undertake both the purchasing and provision functions, or these may be divided up between different organisations. In the English NHS in the 1990s for example, a purchaser–provider ‘split’ was introduced to encourage provider competition in healthcare markets.

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World Book of Family Medicine – European Edition 2015 How healthcare professionals are paid can vary and this can affect the healthcare system’s ability to contain costs and deliver high quality care. Thinking specifically about primary care, for example, family doctors can be salaried, paid through fee-for-service or by capitation – or a blend of all three payment methods. In the most basic sense, salary and capitation payments are often less costly than fee-for-service and in particular in the case of capitation may promote preventive work. However they can lead to doctors over-delegating and under-providing services. Meanwhile fee-forservice places the financial risk on the payer and may potentially increase ‘unnecessary’ activities. Performance-based pay is also often used, which involves paying doctors or groups of doctors for achieving targets on quality indicators. This may lead to improved attention to quality domains, but can also lead to surrogate end points, neglect of non-quality indicators and may disturb the doctor-patient relationship. There are, of course, more incentives than just money. Providers can be incentivised by professional development, clinical guidelines, utilisation reviews, targets, public disclosure, ethics and of course an intrinsic desire to do good! Payments can modify behaviour, but mechanisms to create more incentives generally have greater administrative costs. Their merits depend on the context in which they are made.

Take Home Messages – Finding the Right ‘Blend’ 

Archetypal models and methods generally ignore the complexity of healthcare system financing and conceal similarities and differences. It is unlikely to find a system that, for example, uses tax contributions solely to fund healthcare and reimburses providers using solely capitation-based payments. Most systems in Europe now blend methods to collect, pool and spend healthcare funds.



In order to achieve the policy goals of any healthcare system blended methods of financing are needed to balance the drawbacks of purist methodologies and to align incentives. The input of family doctors as advocates for their patients and as front-line health professionals is important to help find the right blend in each context to meet the desired goals of their healthcare system.

Original Abstract www.woncaeurope.org/content/ws07-do-you-understand-how-your-health-system-works-beveridge-bismarck-whistle-stop-tour-2

WONCA Europe Vienna 2012

In a packed room during the 2012 WONCA Europe conference in Vienna, this workshop set out to provide participants with a framework to compare their own healthcare systems. It was picked up in a column by RCGP chair at the time, Prof Claire Gerada (1), reported in a blog for the London School of Economics and Political Science (2), and the full presentation (available on Prezi) has over 3000 views (3).

References 1. 2. 3.

http://email.rcgp.org.uk/rp/440/process.clsp? EmailId=139125&Token=29A76D1D621057493A98ECFE1394744DC&utm_campaign=RCGP_Update_| _4_November_2011&utm_medium=Email&utm_source=CM_RCGP http://blogs.lse.ac.uk/healthandsocialcare/2012/07/10/how-does-your-health-system-work-a-workshop-at-the-woncaeurope-conference-2012/ https://prezi.com/ba6bcwlco-ge/from-beveridge-to-bismarck-a-whistle-stop-tour-of-european-health-systems/

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World Book of Family Medicine – European Edition 2015 Francine Lemire, MD CM, CCFP, FCFP [email protected]

30 – The Transition from CME to CPD - Fostering Good Practice Through Education Francine Lemire, MD CM, CCFP, FCFP Co-authors Marlow, Bernard; Rock, Susan; Meuser, Jamie

Introduction The College of Family Physicians of Canada is a voluntary organization of Family Physicians, which makes CME/CPD mandatory. Over ninety percent of its members have obtained Certification, which is an indicator of special competence in the discipline of Family Medicine. In 1997, the CFPC introduced Mainpro-C activities, which aim to have more of an impact on practice than traditional CME, by encouraging physicians to reflect on the impact of the learning on their practice. It is well recognized that the determinants of good practice go far beyond disease management and the role of clinical expert. We utilized eight identified physician roles:  medical expert,  communicator,  collaborator,  health advocate,  learner,  manager (gatekeeper),  scholar,  and "physician as person", as a model consistent with good practice and meeting societal needs. Currently, Medical Regulatory authorities in Canada are reviewing the integration of a physician's CPD/CME portfolio as a component of revalidation of licensure. In this study, we will review the past Mainpro-C activities of our members based on the identified physician roles.

From CME to CPD in a Regulatory Context of Physician Practice Improvement The College of Family Physicians of Canada is responsible for the accreditation of postgraduate residency programmes in family medicine in each of Canada’s 17 faculties of medicine. It is responsible for the creation and administration of examinations leading to Certification in Family Medicine and a Certificate of Special Competence in Emergency Medicine. It is also responsible for setting the criteria for Maintenance of Certification, and for supporting all family physicians in their commitment to lifelong learning. Since 2007, most medical regulatory authorities are mandating that physicians demonstrate such commitment through participation in an accredited programme of continuing Professional Development (CPD) by either the CFPC or the Royal College of Physicians and Surgeons of Canada (RCPSC) for specialties other than family medicine.

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Context Several factors have stimulated reflection and evolution regarding CFPC’s maintenance of certification programme: 1. Team based care; 2. Greater importance of work-based learning; 3. The need for reflection about impact of learning on practice, given the evidence to support the importance of this step to support practice improvement; 4. Regulatory context in which increasingly physicians will need to demonstrate maintenance of competence and a commitment to practice improvement.

Action The CFPC will be introducing an enhanced programme of maintenance of Certification, Mainpro+, in July 2015. It aims to support family physicians better in assessing their learning needs, to help them to capture the many ways in which they further their learning in all spheres of practice, and to reflect on the impact of each learning activity on their practice. Mainpro+ has three categories of CPD activities: Group Learning, Self Learning, and Assessment, with subcategories (Certified and Non-Certified) within each group. There will continue to be a yearly minimum requirement of credits for each five year Mainpro cycle. CPD activities that stimulate learning in all the roles expected of physicians (Collaborator, Communicator, Manager/Leader, Professional, Scholar, Health Advocate, Medical Expert-Definitions based upon CanMeds-FM) will be encouraged and incentivised, and recognition of the learning needed to excel at teaching, research, and administration as well as clinical work. All participants will be encouraged to develop a learning plan at the beginning of their cycle. For those family physicians who have acquired enhanced credentials in a focused area of practice, there will be a minimum number of credits required to address that practice domain. The CFPC, along with several other medical professional organizations, will build upon the Future of Medical Education in Canada (FMEC) project, to be part of a consortium working towards a CPD system that can consistently address evolving needs and priorities. The 3-year planning phase will be co-chaired by CFPC and the Royal College of Physicians and Surgeons of Canada. Describing and bringing these future directions to life will be accomplished through commissioning a series of collaborative projects to address important questions that will have a bearing on the future of CPD and the role(s) of a future Consortium (e.g. How will CPD activities be funded? What will be the role of patients and the public in setting priorities? How will team-based care be reflected in the setting of learning? etc.). The FMECCPD project will leverage the high degree of collaboration and conjunction of interest that already exists across the many organizations involved in CPD to construct a future pan-Canadian system with an appropriate governance structure that can respond more completely to the diversity of physician, provider, and societal health care needs. We have good evidence that clinicians who commit to lifelong learning perform better in practice. Mainpro+ aims to facilitate such engagement. The FMEC-CPD project will include a robust evaluation agenda to confirm collaborative priority-setting to support this learning.

Take home messages 

The context of practice is evolving: team based care, workplace based learning, and increased accountability expected of our profession. Our CPD system needs to evolve to support physicians in their engagement in lifelong learning



CFPC’s new Mainpro+ programme will better support physicians in assessing their learning needs, developing a plan, and measuring the impact of learning on all aspects of their practice. The CFPC is part of a consortium to build upon the Future of Medical Education in Canada (FMEC) project, to build a Pan-Canadian Planning Consortium for CPD. The initial phase of this work will unfold in 2015-2017

Original abstract http://www.woncaeurope.org/content/4488-transition-cme-cpd-fostering-good-practice-through-education

References:  

Meuser J, Hill L, Outschoorn A: Learning to change: Coming updates to the CFPC Mainpro program; Can Fam Physician September 2013 59:913-914 The Future of Medical Education in Canada (FMEC) Continuing Professional Development (CPD): A Strategy for the Development of a Pan-Canadian FMEC CPD Consortium (unpublished)-Development coordinated by the Association of Faculties of Medicine of Canada-last revision August 2014

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World Book of Family Medicine – European Edition 2015   

Goulet F, and all: Effects of Continuing Professional Development on Clinical Performance: Results of a study involving family practitioners in Quebec; Can Fam Physician May 2013 59: 518-525 Lemire F: Mainpro: From improvement of knowledge to improvement of performance; Can Fam Physician September 2013 59: 1020 CanMEDS-Family Medicine: A Framework of Competencies in Family Medicine - See more at: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=3031#sthash.FsnHuFaW.dpuf

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World Book of Family Medicine – European Edition 2015 Annika Bardel, GP, PhD [email protected]

31 – Factors Associated With Adherence to Drug Therapy Annika Bardel, GP, PhD R&D Center/Center for Clinical Research, Sörmland, Uppsala University, Eskilstuna, Sweden Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine Section, Uppsala, Sweden Co-authors Mari-Ann Wallander PhD, Kurt Svärdsudd MD, PhD Uppsala University, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine Section, Uppsala, Sweden

It is well known that lack of patient adherence is of major importance in the success of a prescribed medical treatment. Lack of adherence may result from patient-related factors, or be related to the provider. Various measures to promote adherence have been proposed, ranging from pill counts and use of trace elements to interviews and questionnaire-based methods. Adherence varies with diseases and across methods used. It has for instance, been found that following an acute coronary syndrome, 8–20% of patients discontinue their medication within 6 months. In many chronic diseases, 40–50% of patients do not adhere to the initial treatment beyond 12 months and in women given hormone replacement therapy, as few as 50% still adhere to their medication after one year. Most adherence studies focus on one drug or one type of disease and are typically run only in patient groups. Few have taken a wider perspective. To this end, we carried out a study on medication adherence, defined as persistence of medication or stopped as prescribed, and some of its determinants in middle-aged women in the general Swedish population. The study was carried out in the Uppsala-Örebro Health Care Region in mid-Sweden with a population of approximately 2 million. The study was performed by means of a postal questionnaire and comprised 2991 women willing to participate. The age distribution of respondents and non- respondents was similar. The questionnaire had two parts, the first containing questions on marital, occupational and educational status, tobacco use, and height and weight. The second part of the questionnaire contained questions on drugs prescribed during the past year. For each prescription, information was sought on drug trade name, dosage, duration of medication and whether the drug was currently being taken as prescribed, was ceased as prescribed, was ceased by the woman against prescription, whether the prescription was filled but the medication not started or whether the prescription was not filled at all. If more than five prescriptions were received during the study period, information on drug number six and onwards was given in a free format, but with the same type of information as for the first five. The study population constituted 1406 women who reported having received at least one prescription . Adherence was considered to be satisfactory if the medication was taken or stopped as prescribed; in all other cases it was considered to be unsatisfactory, since the purpose of the study was to study general adherence to prescribed medication, not the occasional loss of individual drug doses. Information was also sought on scheduled check-ups, perceived necessity of the medication (coded from low (=1) to very high (=7)), concerns about medication safety (yes/no) and prescribing physician’s sex and type (general practitioner, hospital physician, private practitioner or occupational health physician).

Mean age was 51 years, mean BMI was 25, 27% had a college or university education. 79% were married or cohabiting, 100

World Book of Family Medicine – European Edition 2015 68% were gainfully employed, 26% were smokers. The number of prescriptions per women ranged from 1 to 15 drugs, with a median of 1.5. Based on 3067 prescriptions among the 1406 women, 85.6% reported satisfactory adherence, with 78% of the medication being currently taken and 7.6% being stopped as prescribed. In 10.7% medication was stopped prematurely, in 1.8% it was never taken and in 1.9% it was not filled at the pharmacy. A total of 207 (14.7%) women reported mixed adherence, satisfactory for some medications and unsatisfactory for others. With relation to 62% of the prescriptions a follow-up appointment with the prescribing physician was given. In 68% the women regarded the medication as important to their health. Seventeen per cent of the women had concerns about the safety of a particular medication. The majority of the prescriptions were for one dose per day or less, 66.6% were issued by a male prescribing physician, in 71% of the prescriptions the confidence in the prescribing physician was reported as high. Most of the prescriptions were issued either by general practitioners (41%) or by hospital physicians (38%). Patient age, a scheduled follow-up appointment, perceived importance of medication, concerns about medication safety, taking respiratory disease medication and taking cardiovascular disease medication remained significantly related to adherence as was seen in a multivariate analysis (Table 1). Among other drug groups the best adherence was found in the groups taking hormonal medications, such as insulin and thyroid hormones, not including hormone replacement therapy or contraceptives. The lowest adherence was found in the women taking musculoskeletal medications, such as non-steroidal anti-inflammatory drugs. Table 1. Factors associated with adherence to medication in multivariate logistic regression with backward elimination of non-significant factors, listed in order of importance. Odds ratios greater than 1.0 indicate that presence of the factor increases adherence, and odds ratios less than 1.0 that adherence decreases. (1) odds ratio, (2) 95% confidence interval Factor

OR (1)

95%CI (2)

Age, years

1.04

1.02-1.06

Check-up appointment scheduled, yes/no

2.51

1.85-3.40

Importance of medication score, 1-7

1.94

1.77-2.12

Concerns about medication safety, yes/no

0.50

0.35-0.73

Respiratory disease medication, yes/no

2.16

1.13-4.14

Cardiovascular disease medication, yes/no

1.80

1.05-3.10

Adherence also varied with various combinations of significant factors in the multivariate analysis. An example is given in Figure 1. Among women 35 years old, who regarded their medication as unimportant and who had no follow-up appointment scheduled, adherence was approximately 15% while among women 65 years old it was 35%. A scheduled follow-up appointment increased adherence by 15–20% units. The change in perceived importance of a medication from unimportant to moderately important increased adherence by 40% units. The best adherence, 95% or more, was found among those who regarded their medication as important and who had a follow-up appointment scheduled, almost regardless of age. Compliance is associated with information giving and positive talk. Patient-centred consultations, when the patient’s points of view are sought by the physician result in higher reported compliance rates. Our findings of high adherence in the group of women with a follow-up appointment is supported by prior findings, where following patients in care is seen as one of the most important adherence interventions. It seems that the patient-provider relationship, when communicative and concordant aspects are developed, may further improve adherence. One way to optimize this relationship is to train the medical providers and students in 101

World Book of Family Medicine – European Edition 2015 communication skills, in order to improve their abilities in creating an optimal consultation within the given time constraints. 100 90

Important medication, check-up scheduled

80 Important medication, no checkup scheduled

70

Moderately important medication, check-up scheduled

60 50

Moderately important medication, no check-up scheduled Unimportant medication, checkup scheduled

40

Compliance, % 30 20

Unimportant medication, no check-up scheduled

10 0 35

40

45

50

55

60

65

Patient age, years

Figure 1 Adherence (%) according to patient age, perceived importance of medication, and given scheduled checkup appointment.

Take home messages 

Arrange for scheduled follow-up appointments to assess the effects of the medication.



Discuss the medication and the importance of taking it as prescribed during the consultation.



Ask about the patient´s concerns with the medication.



Explain disease severity to the patient.



Provide training opportunities for medical students and practitioners to improve communication skills.

Original abstract http://www.woncaeurope.org/content/bp18-factors-associated-adherence-drug-therapy-population-based-study

Reference 

Bardel A, Wallander MA, Svärdsudd K. Factors associated with adherence to drug therapy: a population-based study. Eur J Clin Pharmacol. 2007 Mar;63(3):307-14.

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World Book of Family Medicine – European Edition 2015 Michael Greco [email protected]

32 – Improving Practice Questionnaire - A Patient Feedback Tool for Clinical Governance, Practice Accreditation and Recertification: Where Are We Now? Michael Greco PhD; BTheol; Grad.Dip.Teach (Sec); GAICD Chief Executive, CFEP Surveys

Introduction The voice of the patient is becoming increasingly recognized as a significant indicator of quality. The patient is envisaged as an important part of developing new services, and ensuring quality improvement across the various levels of the health care system. A recent systematic review published in the BMJ showed that patient experience is linked to clinical effectiveness and patient safety (1). So how can practices gather robust, valid and reliable data on patient experience? And how can this data be helpful in supporting the practice to improve its quality? The Improving Practice Questionnaire (IPQ) is a patient feedback instrument that combines both the general issues around primary care, such as access, availability of information, preventive care and health promotion, as well as the patient’s experience of the clinician’s interpersonal skills in the consultation (2).

Spread The IPQ was extensively used across UK primary care practices (over 4,000) as part of the evidence required for the Quality Outcomes Framework (QOF) (3). In Australia, the IPQ is called the Practice Accreditation and Improvement Survey (or PAIS) and has been approved by the RACGP as part of its 4th Edition Quality Standards (commencing 2011) for practice accreditation (4). Over 3,500 Australian practices are involved in using the tool. Several other countries have adopted the tool including New Zealand and the Republic of Ireland. However, just undertaking a valid and reliable patient survey is not enough. The real challenge begins when healthcare organisations receive their results and reflect on their significance. Research evidence shows that these organisations do better when they build action plans around their results of patient feedback, and even more so, when patients are involved in the proposed improvement strategies. This process has been referred to as ‘Critical Friends Groups’ (5). At the individual level, clinicians can receive feedback on their interpersonal skills. In the UK, doctors are using this evidence as part of their requirements for Revalidation (6). In Australia, where revalidation does not yet exist, the IPQ is being utilised by doctors for their CPD requirements. Increasingly, the tool is being linked to MultiSource Feedback (MSF) which is becoming more widely adopted across health practitioner recertification/revalidation (7).

So What Next? Although several countries are now embedding systematic patient feedback into their

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World Book of Family Medicine – European Edition 2015 quality requirements, there is still little known about how practices reflect and respond to their feedback. More research is needed in the area of what actions, based on patient feedback, lead to improved outcomes. Another issue is that systematic patient feedback has been largely adopted by medical organisations because of quality requirements. However, there seems to be little uptake among other primary care providers such as dentists, pharmacists, physiotherapists and other allied health professionals. This apparent neglect of patient feedback is beginning to change. For example, the Pharmacy Guild of Australia has recently engaged their pharmacies in patient feedback as part of their Quality Care Pharmacy Program (8). However, to ensure further uptake by allied health professionals, more needs to be done to incentivise them in not only measuring patient experience, but also embedding such feedback into their quality review processes.

Take Home Messages 

Patient experience and its measurement is key for providing evidence of quality and safety across healthcare organisations.



The Improving Practice Questionnaire has been extensively used in the UK, Australia, Ireland and NZ.



It provides feedback at both the organisational and individual levels of performance to help provide evidence for practice accreditation and practitioner recertification/revalidation.



Approximately 4 million questionnaires have been analysed across 10,000 organisations, however more needs to done in other allied-health professions.



More research is needed on the impact of the tool in terms of improving quality at both organisational and individual levels.

Original Abstract http://www.woncaeurope.org/content/221-improving-practice-questionnaire-patient-feedback-tool-clinical-governance-practice

References 1. 2. 3. 4. 5. 6. 7. 8.

Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570 Greco, M.; Powell, R. and Sweeney, K. 2003. The Improving Practice Questionnaire (IPQ): a practical tool for general practices seeking patient views. Education for Primary Care. Vol.14: 440-448. Powell RJ, Powell, HJ and Greco MJ (2008) The impact of patient survey feedback in general practice: the influence of practice size. Journal of Management & Marketing in Healthcare, Vol 1, No.2, 202-213. Greco, M.; Sweeney, K.; Brownlea, A. and McGovern, J. 2001. The Practice Accreditation and Improvement Survey (PAIS) – what patients think. Australian Family Physician. Vol.30, No.11, 1096-1100. Greco, M.; Carter, M.; Powell, R.; Sweeney, K.; Jolliffe, J. and Stead, J. 2006. Impact of patient involvement in general practice. Education for Primary Care. Vol.17: 486-95. Narayanan, A. and Greco, M. 2007. What distinguishes general practitioners from consultants, according to colleagues? Journal of Healthcare Management and Marketing. Vol.1 No.1: 80-87 Campbell, J., Narayanan, A., Burford, B. and Greco, M. 2010. Validation of a multi-source feedback tool for use in general practice. Education for Primary Care. Vol.21, 165-179. Narayanan, A., Greco, M. Reeves, P. et al. 2014. “Community pharmacy performance evaluation: Reliability and validity of the Pharmacy Patient Questionnaire (PPQ)”. International Journal of Healthcare Management. Vol.27, 103-119.

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World Book of Family Medicine – European Edition 2015 Ursula Reichenpfader, MD, MPH [email protected]

33 – Health Promotion In European General Practice – Opportunities and Challenges from a Research Perspective Ursula Reichenpfader, MD, MPH Department of Medical and Health Sciences - Division of Community Medicine, Linköping University, Sweden Co-authors Petra Plunger, Institute for Palliative Care & Organisational Ethics/IFF/Alpen Adria University Klagenfurt – Wien – Graz, Austria Karl Krajic, FORBA Working Life Research Centre, Vienna; University of Vienna, Austria

Background - Health Promotion in General Practice: the Project The project "Health Promotion in Primary Health Care - General Practice and Community Pharmacy", commissioned by the European Commission, brought together professional associations of general practice/family medicine (GP/FM) and community pharmacy from all participating EU member states. Conceptually developed and coordinated by the Ludwig Boltzmann Institute for the Sociology of Health and Medicine in Vienna, WHO Collaborating Centre for Health Promotion in Hospitals and Health Care, and supported by a European expert group, this project aimed to contribute to the development of quality assured patient-/user-oriented health promotion in GP/FM and community pharmacy in the - then - 15 member states of the European Union (http://www.univie.ac.at/phc/e/tx_1020_85.htm ). The main objectives were to strengthen health promotion perspectives in professional health care settings, and to further European exchange and mutual learning. Based on a systematic literature search, consultations with project participants, and country reports, we provided an overview of the state of health promotion in these two settings. In a further step, the partners of the project formulated proposals as to how the European Commission could support the further development of health promotion in both settings. Our literature review revealed that health promotion in GP/FM was an underresearched topic. However, health promotion was explicitly recognized as an integral part of the professional role of the GP in several policy statements both at the European and the national level. Nevertheless, health promotion and relevant skills and competencies did not figure very prominently in professional education and training. As to reported health promotion activities, we identified several models and initiatives, albeit with only very few systematically designed and evaluated intervention studies; research on interventions and their effectiveness mostly referred to risk-factors and disease-oriented interventions. Health promotion and prevention activities provided in routine GP/FM had an emphasis on individually oriented interventions, including health-checks, opportunistic screening, and lifestyle counselling, vaccinations and participation in national cancer screening programs.

Opportunities General practitioners (GPs) are considered well positioned to provide health promotion and preventive interventions. GP/FM is usually the point of first and low threshold contact for a large segment of the population and deals with a wide range of health issues. Given the nature of problems presented in GP/FM consultations, Gps are responsible for longitudinal continuity of care, often have established trusting relationships with their patients over 105

World Book of Family Medicine – European Edition 2015 time, and develop a person-centred approach (1). Furthermore, patient attitudes towards lifestyle advice by GPs are positive, specifically regarding advice on dietary habits, physical exercise and smoking (2). Research suggests that brief lifestyle advice by primary care physicians can be effective, such as advice to promote smoking cessation, reduce harmful drinking, or improve nutrition behaviour, especially when offered to patients at risk of chronic conditions rather than to an unselected healthy primary care population. Interestingly, evidence also shows that more intensive interventions do not result in additional health benefits (3-5).

Challenges Despite all these opportunities, wide-ranging implementation of health promotion, especially of more communicationintensive interventions, as well as prevention in routine GP/FM practice still seems to remain low. Patients report low rates of lifestyle advice and counselling by physicians in primary health care and often perceive their GPs not sufficiently interested in delivering such interventions. Research exploring barriers to provide health promotion as perceived by primary health care physicians identified the following factors: perceived lack of time or competing work load, insufficient reimbursement, doubts about patients’ acceptance and willingness to receive lifestyle counselling, low self-efficacy, insufficient skills and training, doubts about effectiveness of interventions, and health promotion perceived as outside professional role (6). As these perceived barriers may differ, ranging from factors associated with the individual practitioner to factors dependent on organizational or systems’ context (7), strategies to address these barriers and to influence professional practice will also vary. They include interventions to enhance professional competencies (i.e. professional education, audit and feedback, or quality assurance projects), financial incentives and improved regulatory contexts, or organizational measures for physicians (explicit inclusion in occupational roles, skill mix changes, integration of GP/FM in multidisciplinary teams, integration of different providers/services).

Current and Future Perspectives While we were unable to carry out an update of our review, we found indications that the aim to better integrate health promotion in today’s GP/FM has not been fully achieved. Thus, how can evidence-based effective health promotion interventions successfully be implemented in routine GP/FM? Results from implementation research call for a structured and multi-faceted approach: so-called tailored implementation interventions, i.e. strategies designed to achieve desired changes in professional practice based on an assessment of relevant determinants, are needed. There is evidence that efforts to change professional practice have a higher likelihood of success when relevant barriers are identified in advance and taken into account (8). So far a majority of the tailored interventions investigated has been oriented at the individual provider, predominantly as educational interventions, while other strategies, like skill-mix development or multidisciplinary teams, have not been equally explored. Future activities as to how health promotion interventions can be better integrated in GP/FM should move beyond the traditional linear “from research-to-practice” approaches to more collaborative and flexible ones. More consideration should be given to actively involve patients and health care practitioners in designing research interventions and, research designs should more carefully address local and socio-cultural contextual factors in order to increase acceptability and sustainability. Before transferred into routine practice, such innovative strategies should then be tested using an appropriate methodological framework. Take Home Messages 

General practitioners are considered well positioned to provide health promotion and preventive interventions.



Implementation of health promotion and preventive interventions in routine GP/FM practice still remains low.



Multiple barriers to health promotion implementation in GP/FM have been identified.



Tailored implementation strategies with collaborative and flexible approaches should be explored to better integrate health promotion interventions in GP/FM.

Original Abstract http://www.woncaeurope.org/content/279-health-promotion-european-general-practice-%E2%80%93-overview

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References 1. 2. 3. 4. 5. 6. 7. 8.

Nutting PA. Health promotion in primary medical care: problems and potential. Preventive medicine. 1986;15(5):537-48. Brotons C, Drenthen AJ, Durrer D, Moral I. Beliefs and attitudes to lifestyle, nutrition and physical activity: the views of patients in Europe. Family practice. 2012;29 Suppl 1:i49-i55. Kaner EF, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, et al. Effectiveness of brief alcohol interventions in primary care populations. The Cochrane database of systematic reviews. 2007(2). Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. The Cochrane database of systematic reviews. 2013;5. Ball L, Johnson C, Desbrow B, Leveritt M. General practitioners can offer effective nutrition care to patients with lifestylerelated chronic disease. Journal of primary health care. 2013;5(1):59-69. Geense WW, van de Glind IM, Visscher TL, van Achterberg T. Barriers, facilitators and attitudes influencing health promotion activities in general practice: an explorative pilot study. BMC family practice. 2013;14:20. Rubio-Valera M, Pons-Vigués M, Martínez-Andrés M, Moreno-Peral P, Berenguera A, Fernández A. Barriers and Facilitators for the Implementation of Primary Prevention and Health Promotion Activities in Primary Care: A Synthesis through MetaEthnography. PLoS ONE. 2014;9(2):e89554. Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. The Cochrane database of systematic reviews. 2010(3).

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World Book of Family Medicine – European Edition 2015 Justin Allen FRCGP [email protected]

34 – How the UK Discovered Europe Justin Allen FRCGP President of EURACT 2001 - 2005

Background In the United Kingdom over the last 15 years arrangements for the provision of specialty training for general practice and its supervision have undergone several reorganisations, and one of the major changes has been the development of a general practice curriculum. Specialty training for general practice lasted for three years, in six month training posts, two years in hospital and one year in an approved general practice placement. It may surprise you to know that until 2005 there was no comprehensive GP curriculum in the UK. Although there was high quality practice-based teaching, the governance and supervision arrangements were fragmented and inconsistent. The approval of hospital posts for GP training was vested in Royal College of the specialty concerned rather than the general practice college. The Joint Committee on Postgraduate Training for General Practice (JCPTGP), a statutory committee of the RCGP and the GP Committee of the British Medical Association (BMA) was responsible for approving general practice trainers, training placements and the issue of certificates of satisfactory completion of the training programme. The Joint Committee on Postgraduate Training for General Practice (JCPTGP), a statutory committee of the RCGP and the GP Committee of the British Medical Association; this committee was responsible for approving general practice trainers, training placements and the issue of certificates of satisfactory completion of training, given by an approved trainer. To add to this chaotic mix, the supervision of hospital training for GPs rested with the specialty college concerned. All medical colleges except general practice were supervised by a different national body, the Specialty Training Authority (STA). All these bodies were responsible to the overarching supervisory body in the UK, the General Medical Council (GMC). The GMC was also separately responsible for the undergraduate curriculum and performance matters of working doctors. As a result of some major governance issues in the UK involving patient harm (for example Harold Shipman) the government decided that the whole governance process was in need of reform, to avoid duplication and possible confusion of roles and responsibilities, not helped by the number of acronyms! The STA and JCPTGP were to be abolished and replaced by a single body, the Postgraduate Medical Education and Training Board. One of the strangest anomalies of the former system was that the RCGP had a very good final assessment exam but this was not approved for use as the national outcome assessment and a different system of assessment ran in parallel.

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World Book of Family Medicine – European Edition 2015

My Input In 2005 the RCGP was given the responsibility for developing a national curriculum for GP training, including assessment. It is at this point that I joined in the fun, having been invited to join the RCGP curriculum group, as I had some knowledge of work going on in Europe on curriculum development. The curriculum group was running a symposium on curriculum development at a WONCA conference entitled: “Developing a National Curriculum for the Education and Training of General Practitioners in the United Kingdom” This symposium looked at the process the Royal College curriculum group were undertaking in designing a new GP curriculum. The RCGP prides itself on the quality of its work and set about its task with its customary academic rigour and energy; it had already started this process when I joined, having started a programme of focus groups, trainee and educator surveys, presentations and workshops at national and international meetings. It had commissioned a literature review and was starting a process of considering other general practice curriculum models that had been developed elsewhere – one from the Oxford region in the UK, and nine from other countries: Australia, Canada, Denmark, Ireland, the Netherlands, Norway, Portugal, Spain and the USA. The observant will have noticed that four of the countries are native English speakers and that the remainder are from the WONCA European region (Ireland fits both categories). Even so the RCGP group were having difficulties in finding a good match for a comprehensive training curriculum for GPs in the National Health Service. As a newcomer to the group I was puzzled (I was often puzzled anyway). The Royal College of General Practitioners was an active member of WONCA Europe and its network organisations which had produced the 2005 European Definition (1) which contained a list of the core competences required to be a GP. EURACT had worked further and developed the European Definition into its Education Agenda (2). This document developed the list of competences into a full blown curriculum statement for European general practice ready for adaptation to the needs of individual countries. But the College did not appear to have considered the European Definition or the Educational Agenda. As we are part of the European Union and as a college have worked hard with our WONCA Europe colleagues, I suggested to the group that we should consider these models. This they did and discovered that with some modifications these documents would be a good basis for the new UK curriculum. With very little dissent, which was possibly related to the fact that the British only speak one language (and that rather badly) the WONCA definition, with its six core competences and three essential features became the basis for the UK curriculum in 2005, and remains so today. The EURACT Educational Agenda is the basis of the core curriculum statement “Being A GP”, and all of the RCGP curriculum statements use the six core competences and three essential features - see for yourself on the RCGP curriculum web site: http://www.rcgp.org.uk/training-exams/gp-curriculum-overview.aspx .

Take Home messages 

Until 2005 there was no comprehensive national GP curriculum in the UK.



Governance of GP training was by a number of bodies, with overlapping roles. GP and hospital training were supervised by different organisations.



The national GP curriculum in the UK has now been developed, and is based on the WONCA Definition of General Practice and the EURACT Educational Agenda.

Original Abstract http://www.woncaeurope.org/content/3553-developing-national-curriculum-education-and-training-general-practitioners-united

References 1. 2.

The European Definition of General Practice/Family Medicine 2005 Edition http://www.woncaeurope.org/sites/default/files/documents/Definition%202nd%20ed%202005.pdf (accessed 19/12/14) The Educational Agenda 2006 ed. J.Heyrman, Leuven, http://www.euract.eu/official-documents/finish/3-official-documents/93-euract-educational-agenda (accessed 19/12/14)

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World Book of Family Medicine – European Edition 2015 Claire Collins, PhD, MSocSc, BSocSc, Dip Stat [email protected]

35 – Health Needs Assessment Claire Collins, PhD, MSocSc, BSocSc, Dip Stats Irish College of General Practitioners, Dublin, Ireland

What is a HNA? “Health needs assessment (HNA) is a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities” (NICE, 2005). It is not only the process of identifying the health needs in the community but also an exploration of all the resources involved - how they are used and how they could better be used - and where they are lacking. It is used to inform decision making and should lead to change which benefits the health of the target population, usually within finite resources – it is therefore necessary to be realistic about what you are capable of achieving from a practical, clinical and economic position. It is important to consider that many factors influence health and therefore numerous individuals, groups and institutions/bodies have a role to play in the health arena. It is accepted that a HNA will produce benefits on multiple levels; these may include: 

strengthening community involvement in decision making



improved public/patient participation in planning services



improved team and partnership working



professional development of skills and experience



increased understanding of local health issues



improved patient care/improved health of people in your community/practice



improved communication with other agencies and the public



demonstrate the reasons for decisions about health care



better use of resources, services and people.

What Does a HNA Involve? The steps involved in a HNA are outlined in many toolkits – Figure 1 outlines the five key steps from one of these (NICE, 2005). In brief, data collection in a HNA in primary care will likely include existing practice data, routinely available local statistics, a patient/public consultation exercise, and a mechanism to obtain public and professional perspectives on need. The latter two may include such activities as questionnaire surveys, interviews, focus groups, casework information and observations. It will most likely be necessary to determine need priorities in consultation; questions which may help this process relate to the numbers affected (absolute or comparatively), equity, impact, changeability, availability of effective and appropriate interventions, the provision of adequate services, the existence of expertise, local and

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World Book of Family Medicine – European Edition 2015 national priorities/strategies, acceptability and resource feasibility. Planning and implementing actions is the most important part of a HNA and involves setting clear aim(s) and objectives, agreeing a shortlist of potentially effective interventions or actions and specifying the resources required (people, space, time and equipment). Evaluating successes and failures and continuous monitoring are part of the process. Effective outcome evaluation requires setting indicators (measures against which to monitor progress) and targets (the level of outcome you want to achieve, for whom and by when).

Guiding Principles and Notes for Primary Care The many authors who have written on the subject take different theoretical perspectives and propose diverse approaches. Furthermore, a HNA may be conducted at different levels (European, national, local, individual etc). However, the guiding principles when conducting a HNA are: 

Be clear about your aim(s) from the very start as this will determine your approach.



The negotiations leading up to a needs assessment are important to determine what sort of evidence of 'neediness' you will have to demonstrate to convince decision makers.



There are many different concepts of ‘need’ e.g. felt need, expressed need etc.



Different information sources and methods of investigation tell you about different aspects of ‘need’ – a mix of sources/methods will build a broader picture of need.



The way you undertake a needs assessment is important and ideally you should use a method that allows you to start to work on the solution to a problem while you are assessing it.



The needs assessment should be owned by the people who will have to implement the actions.



Health needs assessment should fit in with the appropriate decision making/planning system e.g. team, local, regional etc.



Health needs assessment is not an end in itself but a means to help plan the future.



Health needs assessment is a part of a cyclical process and should include an evaluation of how the needs have been met and not met by the actions taken.

Kilduff et al (1998) highlight the need for primary health care teams (PHCTs) to understand their stage of development and how this will directly affect any health needs assessment, and discusses the place of health needs assessment within the general processes and systems of the PHCT. A diagnostic and development tool, which links together the intimate relationships between five stages of development needed for effective primary care-oriented health needs assessment work, is outlined. The BMJ has produced a series of six articles on HNA which give a useful overview and direction, and contain many useful references for further and directed reading. Of particular interest for primary care is the first of these articles which points to the importance of distinguishing between individual needs and the wider needs of the community in the planning and provision of local health services; ignoring these needs can lead to a topdown approach to providing health services, which relies too heavily on what a few people perceive to be the needs of the population rather than what they actually are. The third article moves HNA from theory to practice; it notes that the assessment of individual's needs may form part of the assessment of a population's needs and outlines the circumstances favouring individual needs assessment for planning purposes. The fourth article in the series focuses on HNA in primary care (albeit in the UK) and identifies the different levels at which a HNA might be conducted and the related approaches and methods. The fifth article in the series highlights the importance of and scope for greater consultation with the general public and with current users about needs and priorities. It points to a need to acknowledge limitations to professional knowledge as well as to respond to inequalities in health (BMJ, 1998).

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World Book of Family Medicine – European Edition 2015 Step 1 Getting started What population? What are you trying to achieve? Who needs to be involved? What resources are required? What are the risks?

Step 2 Identifying health priorities Population profiling Gathering data Perceptions of needs Identifying and assessing health conditions and determinant factors

Step 5 Moving on/review Learning from the project Measuring impact Choosing the next priority

Step 3 Assessing a health priority for action Choosing health conditions and determinant factors with the most significant size and severity impact Determining effective and acceptable interventions and actions

Step 4 Planning for change Clarifying aims of intervention Action planning Monitoring and evaluation strategy Risk-management strategy

Figure 1: The five steps of health needs assessment

Take Home Messages 

HNA is an approach that helps plan services that tackle ‘needs’ rather than just reacting to demands.



HNA is a multidisciplinary and multisectoral activity and consultation is a key component.



HNA is not only about assessment but also about taking action to improve the health of the population.



Aim for small, achievable, measurable goals; this increases the chance of success.



HNA is not an end in itself.

Original Abstract http://www.woncaeurope.org/content/theme-b-needs-assessment-general-practice-family-medicine

References        

BMJ. Series of articles on ‘Health needs assessment’ online: BMJ 1998; 316 (April to June 1998): http://www.bmj.com/content/316/ Gillam, S. & Murray, S. (1996). Needs assessment in general practice. London: RCGP occasional paper. Harris A. (1997) (ed). Needs to Know: a guide to needs assessment for primary care London: Churchill Livingstone. Hooper J, Longworth F (1997). Health needs assessment in primary care. A workbook for primary health care teams. Calderdale and Kirklees Health Authority. Kilduff A, McKeown K, Crowther A. Health needs assessment in primary care: the evolution of a practical public health approach. Public Health. 1998 May;112(3):175-81.PMID:9629025. NICE (2005) Health Needs Assessment: a Practical Guide. http://www.gserve.nice.org.uk/nicemedia/documents/Health_Needs_Assessment_A_Practical_Guide.pdf Scottish Needs Assessment Programme (1998) Needs Assessment in Primary Care: A Rough Guide. Glasgow. WHO Community health needs assessment (2001) An introductory guide for the family health nurse in Europe. http://www.euro.who.int/__data/assets/pdf_file/0018/102249/E73494.pdf

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World Book of Family Medicine – European Edition 2015 John Salinsky, MD, FRCGP [email protected]

36 – The Balint Experience John Salinsky, FRCGP General Practitioner and Training Programme Director Whittington GP Education and Training, London, UK.

The Early Days of Balint Balint groups are named after the psychoanalyst Michael Balint (1896-1970). In the late 1950s, Michael and his wife Enid began holding psychological training seminars for GPs in London. This work was first described in the book The Doctor, his Patient and the Illness (1957). There were no lectures and the doctors’ education was based on case presentation and discussion in a small group of nine or ten with a psychoanalyst leader. To begin with, Balint encouraged the group members to hold ‘long interviews’ with their problem patients. This helped the doctors to concentrate on becoming good listeners. Subsequently the focus changed to studying the relationship between doctor and patient in the context of every day ordinary-length consultations. The groups met once a week for a number of years so that patients and their progress could be followed up. The continuity also enabled group members to feel at ease with other. Since those early days, Balint groups have spread across the world and in 20 countries there are national Balint Societies whose aim is to foster and develop the Balint approach.

Balint Groups Today: What Happens? The group members and the leader sit in a circle and the leader (or one of the leaders if there are two) asks ‘who has a case?’ Someone volunteers to talk about a patient who has been on her mind. The problem may be that the patient has been emotionally disturbing or just difficult to understand or to engage in treatment. The group listens to the story without interrupting. When the presenter has finished, the leader invites the group to respond to what they have heard. Responses take various forms. There may be questions, advice to the doctor, emotional reactions induced by the patient’s story and speculations about what else might be going on. The group leader will gently discourage too much interrogation of the presenter, as the aim is to get the group members themselves to work on the case. In a variation of the group process, the leader asks the presenter to ‘sit back’ i.e. to push his chair back a little and to remain silent for the next 20-30 minutes. This effectively prevents the group from asking any more questions and throws them back on their own resources. The presenter is allowed to have her say and respond to what she has heard when she is invited to join in again later.

The Role of the Leaders The leaders’ first aim is to make the group a safe place, where confidentiality is observed and members feel free to talk about their feelings and their work (including their mistakes). The leaders will discourage unwanted and intrusive questions about the presenting doctor’s personal life and history. Personal anecdotes are sometimes volunteered and can be helpful. The leaders will allow this provided there is no pressure. The group is not a therapy 113

World Book of Family Medicine – European Edition 2015 group although its effects can be therapeutic. The leaders’ second aim is to keep the discussion focused on the doctor patient relationship. They may ask how the patient has made everyone feel. Do we feel angry or sad? Do we like the patient and want to help him? Or would we prefer to keep him at a distance? The group may be invited to consider how the patient is feeling or what sort of doctor he wants his doctor to be. A group that dislikes or fears the patient may be unwilling to engage and will try to ‘escape’ by talking about generalities: ‘these patients are always untreatable’ or recommending referral to an expert whom somebody knows. In this situation the leaders will try to bring the group back to the work, perhaps by representing the patient (‘If I were this patient I would be feeling terribly alone and abandoned right now…’) If there are two leaders, they will be trying to work in sympathy, picking up cues from each other. One may steer the discussion while the other watches for people trying to get a word in. Often, the presenting doctor finds herself behaving like the patient, while the group members mirror her own reaction in the consultation.

Ending the Session The session ends, like a therapy session, when time has run out. At least one leader will be keeping a discreet eye on the clock. There may be one or two presentations (including follow-ups) in a ninety-minute session. The leaders may ask for a follow up and thank everyone. They do not attempt to tie the loose ends or give a reassuring summary.

Benefits of Balint What does participation in a Balint group do for a group member? The first and most easily obtained benefit is to have a safe place where you can talk about interpersonal aspects of your work with your patients. The group will be sympathetic and they will all have been in similar situations themselves. This is a great relief and usually means that when a dreaded patient turns up again he or she will cause less anxiety. We believe that the Balint group experience helps to avoid professional ‘burnout’. Are older Balint doctors still enjoying their work? Try asking them! Secondly, the Balint group encourages doctor to see their patients as human beings who have a life and relationships outside the consulting room. They become more interesting to listen to and easier to help. Thirdly, the group members may gradually reach a deeper level of understanding of their patients’ feelings and their own. They may realise that certain patients or emotions may resonate with what is going on in their own inner and outer lives. This may be causing problems which the doctor can learn to avoid or even to turn to therapeutic advantage.

Take Home Messages Taking part in a Balint group can help a doctor to: 

find a safe place to discuss doctor-patient issues



see patients as human beings



reach a deeper level of understanding of the feelings of both patient and doctor

Original Abstract http://www.woncaeurope.org/content/25-balint-group-experience

References  

Balint, M. (1957) The Doctor, his Patient and the Illness. London: Pitman. Millennium edition 2000. Edinburgh: Churchill Livingston. Kjeldmand, D, Jablonski, H and Salinsky, J (2013). Balint Groups and peer supervision. In L Sommers & J Launer (Eds.) Clinical Uncertainty in Primary Care. The challenge of collaborative engagement. New York, Springer.

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World Book of Family Medicine – European Edition 2015 Alan Abelsohn MBChB, CCFP, FCFP [email protected]

37 – Environment and Health in Family Medicine Alan Abelsohn MBChB, CCFP, FCFP Associate Professor, Department of Family and Community Medicine and the Dalla Lana School of Public Health, University of Toronto.

How is the environment that my patient lives in, affecting her health? It is an interesting question, and one most family doctors seldom consider. I will discuss this question from a number of perspectives. Is it important, i.e. how big is the burden on health as a result of environmental factors? There have been a number of estimates of the burden of environmental impacts on health, noting that these impacts are preventable. However, the scope of the definition of environmental health and the methods used vary from study to study, making interpretation difficult. Table 1 lists a selection of the studies. It is clear that the morbidity and mortality from environmental factors is significant. Study

Jurisdiction

WHO (1)

Globally

Scope of Study

Health costs

A broad scope of factors, including chemical and biological pollution in air, water and soil, UV and ionizing radiation, noise and electromagnetic fields, occupational risks, climate and ecosystem change and the effects of the built environment.

24% of DALYs (Disability Adjusted Life Years) 23% of all deaths 36% of deaths in children aged 0-14

WHO (1)

Developed countries

As above

16% of DALYs

Boyd (2)

Canada

Restricted to environmental burden of disease from respiratory disease, cardiovascular disease, cancer and congenital affliction

Annually: 10,000–25,000 deaths, 78,000–194,000 hospitalizations, 8000–24,000 new cases of cancer; and 500– 2500 low birth weight babies, costing between $3.6 billion and $9.1 billion

Developed countries are less affected, as the burden in developing countries includes water contamination, and the large numbers affected by indoor burning of coal and biomass for home heating and cooking, which is responsible for 1.6 million premature deaths and nearly 3% of the global burden of disease in 2000 (3), as well as the suffocating outdoor air pollution of cities like Beijing and Delhi. So let’s consider a case. A 14 year-old girl presents in the emergency department with an exacerbation of her asthma.

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World Book of Family Medicine – European Edition 2015 She had been previously well controlled, on a LABA and Inhaled Corticosteroid combination. What might have precipitated this exacerbation? It could be due to a viral upper respiratory infection, or non-compliance. But to consider possible environmental factors, we suggest taking an “exposure history” using the CHP mnemonic (4). She might be exposed in the following environments. (Table 2) CHOP

Location

Examples

C

Community

Outdoor air pollution from traffic, industry, wood-smoke from a fire, crop burning or home heating/cooking

H

Home

Second-hand smoke; a new pet; cockroaches; House dust mites; water damage and mould; smoke from wood-burning or kerosene stoves or fireplaces; Outdoor air pollution infiltrating inside

H

Hobbies

Clay dust or glazes from pottery/ceramics; paint fumes; solvents; chemicals; baking flour

O

Occupation/ School

Exposures at work or in the school building

P

Personal

Smoking

So asking, or if a house-call is carried out, observation, might reveal the “upstream” provocative factors, which might otherwise not be recognised. And the treatment would be two-fold: treating the asthma exacerbation medically, but also intervening if possible in the environment. For example, community air pollution was increased that day, and the corresponding Air Quality Index was elevated. The family could be counselled that strenuous outdoor activity increases the intake of air pollutants into the airways, and should be reduced when pollution levels are high; and that she should exercise away from traffic as much as possible, because exercising near traffic increases pollutant exposure and reduces FEV1 (5). Environmental health is by definition multidisciplinary, and many of these issues might overlap with Public Health, or other disciplines. For example, a 2 year-old child is found to have a high serum lead level. The source (H in the CHOP mnemonic) is hand to mouth activity so that house dust is ingested; and the dust is contaminated by deteriorating old lead-based paint around the windows. Lead was removed from paint in Canada in 1978. The intervention is to remove the child from the environment, and remediate the house dust/paint situation. Other sources of lead might have been from 

(H-Home) children’s toys or jewellery, lead-soldered pots or glazed pottery;



(H-hobbies) stained glass or pottery and



(P-personal) folk remedies, Ayurvedic products or Asian eye-cosmetics.

But there is another aspect of the environment that, although less immediately clinically relevant, is important to family doctors; namely the health of the planet. Climate change is not just a physical issue; it is very much a health issue. Dr Margaret Chan, director-general of the WHO, called climate change “the defining issue for public health in the 21st century”. The broader perspective of planetary sustainability (6) is being discussed more and more urgently in medical circles. The health effects of climate change are described as direct (heat extremes; severe storms and floods) and indirect, which spans a number of pathways; increased range of vector-borne diseases (Lyme disease in Canada; Chikungunya in Europe and the Caribbean); food insecurity secondary to drought, with resulting malnutrition, water insecurity, and sea level rise which will all lead to the displacement of climate change refugees and the potential for international conflict.

What is the role of family doctors? We should be checking and taking steps to reduce our own and our family’s Carbon footprints: http://www.nature.org/greenliving/carboncalculator/ . In our clinics and hospitals, we should be leading by example, and doing our best to make them ecologically sustainable: “greening” our workplaces. 116

World Book of Family Medicine – European Edition 2015 We are also teachers, and need to impress on the next generations of health care professionals the urgency of tackling these global health threats. Finally, we could be advocates for our planet, advocates for the urgent transformations required by our societies, to gain control of carbon emissions, and reduce over-consumption and inequity. Family doctors are well-respected community based scientists. There is one of us in almost every community around the globe. We are uniquely placed to be effective actors (7). My hope is that we exert our well-deserved influence and credibility, as individuals, and also as medical organizations, in the name of redirecting our planet towards health and sustainability.

Take Home Messages 

Environmental factors are responsible for a significant burden of illness.



Environmental causes of illness are “upstream”, and often not recognized.



An exposure history, using the CHP mnemonic, is a useful clinical tool.



Climate change and planetary sustainability are pressing global issues.



Family doctors have a role in greening their clinics and hospitals, educating the next generation of doctors, and advocating individually and in our organizations, for planetary health.

Original Abstact http://www.woncaeurope.org/content/ws-013-environmental-medicine-family-practice

References 1. 2. 3. 4. 5. 6. 7.

Pruss-Ustun A. Corvalan C. How much disease burden can be prevented by environmental interventions. Epidemiology. 2007;18(1):167-78. Boyd DR, Genuis SJ. The environmental burden of disease in Canada: Respiratory disease, cardiovascular disease, cancer, and congenital affliction. Environmental Research. 2008; 106(2):240-249. Ezzati M. Indoor air pollution and health in developing countries. Lancet. 2005; 366(9480):104-106. Marshall L, Weir E, Abelsohn A, Sanborn MD. Identifying and managing adverse environmental health effects: 1. Taking an exposure history. CMAJ 2002;166(8):1049-55. Available at: http://www.cmaj.ca/cgi/content/full/166/8/1049 McCreanor J, Cullinan P, Nieuwenhuijsen MJ, Stewart-Evans J, Malliarou E, Jarup L, et al. Respiratory effects of exposure to diesel traffic in persons with asthma. N Engl J Med 2007;357(23):2348-58. Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S. From public to planetary health: A manifesto. The Lancet. 2014; 383:847-847. Blashki G, Abelsohn A, Woollard R, Arya N, Parkes WM, Kendal P, Bell E, Bell RW. General Practitioners' responses to global climate change - lessons from clinical experience and the clinical method. Asia Pacific Family Medicine. 2012,11:6

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World Book of Family Medicine – European Edition 2015 Karen Bentley, BM [email protected]

38 – Mentoring – a Quality Approach to Professional Development Karen Bentley. BM DRCOG DGM MRCGP PGCME GP trainer, appraiser, Associate Dean. Wessex Deanery. Hampshire . UK

The term 'mentoring' is derived from the character 'Mentor' in Homers Odyssey. In the story, Mentor was an old friend of Odysseus and was the respected advisor to Telemachus, the son of Odysseus and Penelope. Odysseus entrusted his Son and household to Mentor when he sailed against Troy. The goddess Athena took on the appearance of Mentor in order to guide young Telemachus in his time of difficulty, giving him prudent counsel. Since then, wise and trusted advisers have been called "mentors". Appraisal is now an annual requirement of every doctor registered with the GMC in the UK in order to continue to demonstrate their ongoing fitness to practice. Revalidation occurs in a five yearly cycle enabling a doctor to continue the practice of medicine. Although the process of Mentoring has been around for a long time the advent of annual appraisal has meant that appraisers have identified 'doctors in difficulty' who need the advice and guidance of a mentor with increasing frequency.

So what is Mentoring? "Mentoring is to support and encourage people to manage their own learning in order that they may maximise their potential, develop their skills, improve their performance and become the person they want to be.” (Eric Parsloe) Mentoring is a powerful personal development and empowerment tool. It is an effective way of helping people to progress in their careers and is becoming increasingly popular as its potential is realised. It is a partnership between two people. The MENTOR (the person doing the mentoring) and the MENTEE (the person receiving the mentoring) normally work in a similar field or share similar experiences. It is a helpful relationship based upon mutual trust and respect and is different to coaching an individual. It is for the mentee to find their own path rather than being told what to do. A mentor is a guide who can help the mentee to find the right direction and who can help them to develop solutions to career issues. Mentors rely upon having had similar experiences to gain an empathy with the mentee and an understanding of their issues. Mentoring provides the mentee with an opportunity to think about career options, personal difficulties life hurdles and helps them to progress. A mentor should help the mentee to believe in themselves and boost their confidence and above all do no harm in this relationship. A mentor should ask questions and challenge, while providing guidance and encouragement. Mentoring allows the mentee to explore new ideas in confidence. It is a chance to look more closely at themselves, their issues, opportunities and what they want in life. Mentoring is about becoming more self aware, taking responsibility for your life and directing your life in the direction you decide, rather than leaving it to chance.

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How is it achieved? Usually there is an agreement between the mentee and the mentor for a number of sessions over a period of time. The session length and the number of sessions are predetermined so that dependence on the mentor does not occur. The mentor should have a proven track record of helping others and of continuing self development and continuing professional and personal development. The sessions may consist of whatever the Mentee may bring but the premise of the Mentor is to get the Mentee to 'solve' the problems themselves through the use of powerful questioning and putting the mentee in the driving seat to re-frame the problem and approach it from a different point of view. Powerful questioning should take into account the learning styles of the mentee i.e. Honey and Mumford - Theorists, Activists, Reflectors and Pragmatists. The powerful questioning can then be tailored on these styles so that they are even more relevant to the mentee. This process often begins with the mentee producing a time line and looking at significant life changing events that have occurred that may influence behaviour, to get the mentee to understand why they behave as they do. At the end of the sessions it is implied that the Mentee will have been on a journey of self discovery and been empowered to change their behaviour. This process can be divided into the' five phase' approach to mentoring: Phase One: Contracting and building the relationship: the mentor and mentee build an initial relationship, getting to know one another and building rapport. They establish what the mentee hope to gain from the mentoring and confirm what the mentor has to offer. They jointly agree the mentoring contract. Phase Two: Understanding the Mentee: the mentee describes their current situation and how they would like things to be in the future. This looks at the mentees strengths and weaknesses, skills and experience. Phase three: Analysis: the mentee and mentor work together to apply appropriate frameworks to help the mentee gain awareness and understanding, recognising the patterns of behaviour that are relevant. Phase four: Action Planning: the mentor and mentee identify the options that will extend the range of possibilities for the mentee. This involves looking at problems in different ways and the possibility of acting as 'devil's advocate', to challenge the mentee to change and take a different perspective. This involves considering and comparing the options and helping the mentee to understand the implications of each option in order to work out the best option and create a detailed action plan. Phase five: Implementation and review: this is where the mentee puts their action plan into practice. This is the result of the mentoring process.

The elements of this process are Awareness - understanding what's going on in the here and now, not reacting in ways that are historical and redundant. Alternatives- being able to identify and develop choices for any given situation and not having one way of responding. Authenticity - being able to build genuine relationships with others. Key to the success of mentoring is the relationship established between mentor and mentee, the formulation of a 'contract' between the two parties to reach a successful end point involving a changed behaviour to enable the individual to progress and continue in their career.

Take Home Messages 

The need for Mentoring is increasing.



A contract is needed between mentor and mentee.



The premise is 'Do no harm'.



The mentee should be empowered.



Effective change should be an action plan outcome.

Original abstract http://www.woncaeurope.org/content/mentoring-quality-approach-professional-development

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References    

GMC 'Good medical Practice' (2013) www.gmc-uk.org/guidance/good_medical_practice.asp mentoring.londondeanery.ac.uk/ NHS Thames Valley and Wessex Leadership Academy Mentoring scheme: Resource Pack 2012 Published by the Thames Valley and Wessex Leadership Academy Clutterbuck, D & Megginson, D, Mentoring Executives and Directors (1999)

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World Book of Family Medicine – European Edition 2015 Andre Matalon, MD [email protected]

39 – Pleasures of Doctoring in Family Medicine Andre Matalon MD Dept. of Family Medicine, Rabin Medical Centre, Belinson Campus, and the Dept. of Family Medicine, Tel-Aviv University, Israel Co-authors Martine Granek-Catarivas MD (2) & Stanley Rabin PhD (3) (2) Dept. of Family Medicine, TelAviv University and Clalit Health Services, Sharon-Shomron District (3) Dept. of Psychiatry, Soroka University Medical Centre, and Division of Psychiatry, Faculty for Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel.

Every day family physicians deal with difficult patients and difficult diseases, with disability and death. In many parts of the world, they face crowded waiting rooms, little time for each patient, disrupting telephone calls and financial and administrative pressures (1). Other pressures are those related to the doctors' own personalities such as perfectionism, self criticism, fear of failure or making mistakes or discomfort about uncertainty (2) (3). Feelings of helplessness or guilt are common among them (4). Doctors often feel overworked and under-supported and feelings of loneliness are also common (5). When family medicine is practised in a hostile environment with the threat of malpractice, doctors adopt a defensive position where their personal and professional well being is jeopardized, nibbling at their ability to enjoy their profession. But, in every simple day of work of any family physician, there are plenty of pleasurable moments, laughter, intimacy and closeness, moments of trust, compassion, love and warmth. Based on a qualitative review of Balint groups with residents (6) and on focus groups of tutors and specialists in family medicine, three themes could be identified regarding the pleasures of doctoring: the professional, emotional and contextual gratifications.

Professional Gratification Family physicians expressed their enjoyment in practising holistic medicine, their ability to deal with almost all aspects of medicine, from cardiology through infectious diseases and psychiatry. This diversity guaranteed a continuous interest in their work. Some of the doctors expressed feelings of accomplishment when performing simple surgical procedures or actions that brought immediate relief from pain or disease. They described sharing the joy and prompt relief obtained after opening an abscess, excising an infected ingrown toenail or reducing a dislocated elbow. They expressed that there was no greater gratification than when the patient left the office without pain. Gratification was also felt in making a precise diagnosis, at the right time. This would happen especially when a diagnosis led to a dramatic change in the patient’s health, which further on, would also lead to a better doctor-patient relationship, recognition, respect and trust. To decide to treat difficult problems alone and succeed was also stated as immensely rewarding. The courage to treat difficult issues on one’s own, with the cooperation and full participation of the patient in the decision-making process was another source of much joy.

Emotional Gratification We found a second group of expressions of emotional gratification that brought comfort and pleasure.

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World Book of Family Medicine – European Edition 2015 One doctor described how good he felt when he examined a child who did not cry, even after forcing a wooden tongue depressor into his throat. He felt special pleasure in conquering his trust, and the trust of the child's parents accepting his explanations about him having "just" a viral infection. Other doctors described their satisfaction in caring for their dying patients and their families, discovering the real meaning of assistance when easing the physical pain of the body, or the emotional anguish in a cancer patient. They felt at their best in their ability to break bad news and to handle the anxiety and depression that followed. The emotional price paid by the doctor in his involvement gave him a feeling of spiritual uplifting. They felt that this was family medicine at its best. Many doctors shared the pleasure obtained through continuity of care, so characteristic of the profession, and the simple joy of knowing their patients. Powerful sources of pleasure were going out into the waiting room of the clinic, welcoming a patient-friend, calling him by his/her name, giving a strong and affectionate handshake, or a gentle touch on the shoulders while leading the patient from the waiting room to the examination room. Knowing precisely the appropriate opening phrase for each patient, from their last vacation to football, or directly addressing the patient’s suffering were also pointed out to be most satisfying. Physicians related to their feelings of affection that grew with time, while accompanying the personal, familial or health crises of their patients: “It’s the mutual respect, trust and friendship that develop over time that I especially enjoy.” The awareness that one has the ability to care and feel positive feelings, like a mother who discovers her ability to parent and love, was, in itself, gratifying to the participants.

Contextual Gratification Many rural doctors live and work in the same community as their patients, or have personal friends as patients. Although this situation may cause problems, most of the doctors reported more satisfaction than problems. Some doctors reported their joy and pride at being invited to the weddings of their patients or being treated with a special respect by the community grocer or by the car mechanic. These satisfactions may have been unwarranted, yet the pride and respect doctors felt from their special status in the community were sources of special joy to them. With regard to the issue of professional status, the doctors, mainly the residents, reported that family doctors sometimes enter into competition with other profession specialists, wishing to win their collaboration and approval. While the disrespect some residents felt from hospital doctors was translated into indignation, earning the respect of colleagues was reported as a source of satisfaction. Hospital-based colleagues regarded the decision to become a family doctor as going down the easy path. Yet, most of the residents opted positively for a career in family medicine. Identifying and understanding the rewards and gratifications of their professional choice helped these family doctors overcome any insinuation that they took the easy option.

Conclusion The joy we experience with our work radiates to the entire environment and to the patients in particular, fostering their well being and the well-being of the doctors as well. Pleasurable insights achieved in Balint groups or in workshops on the pleasures of doctoring can serve as another source of gratification and can help in preventing burnout.

Take Home Messages 

Family physicians often deal with difficult patients, crowded waiting rooms, little time with patients and administrative pressures.



Other pressures are related to the doctors' own personalities such as perfectionism, self criticism or fear of making mistakes.



But, in every day of work of any family physician, there are plenty of pleasurable moments, laughter and intimacy.



Three themes were identified regarding the pleasures of doctoring: professional, emotional and contextual gratifications.



Pleasure in doctoring radiates to the entire environment, fostering both patients' and doctors' well-being.

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Original Abstract http://www.woncaeurope.org/content/451-pleasures-doctoring-family-medicine

References      

Williams ES, Linzer M, Pathman DE, McMurray JE, Konrad TR. What do physicians want in their ideal job? J Med Pract Manage. 2003 Jan-Feb; 18(4):175-6. Brock CD, Johnson AH. Balint group observations: the white knight and other heroic physician roles. Fam Med. 1999 Jun; 31(6):404-8. Edwards N, Kornacki M J, Silversin J. Unhappy doctors: what are the causes and what can be done? BMJ 2002; 324:835838 Balint M. The doctor, his patient and the illness. London, Pitman, 1957. Smith R. Why are doctors so unhappy? BMJ 2001; 322:1073-1074 Matalon A. The pleasures of doctoring as seen through reflections in Balint groups. Psychodinamische Psychotherapie 2010; 9: 176-182 (Ger)

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World Book of Family Medicine – European Edition 2015 Teresa Pawlikowska BSc MB BS MSc PhD DRCOG MRCP [email protected]

40 – Measuring Effectiveness in General Practice / Family Medicine Teresa Pawlikowska BSc MB BS MSc PhD DRCOG MRCP Professor and Director Health Professions Education Centre, RCSI, Dublin, Ireland.

Context Increasing patient involvement in their own care, and its evaluation, is an important feature of health service development. Donabedian has conceptualised effectiveness into technical and interpersonal aspects: the latter is explored here. McWhinney defined general practice as working with undifferentiated problems, patient -focused, and stressed the importance of the doctor-patient relationship. All definitions of the role of general practitioner (The Leeuwenhorst Group 1974, the European Academy of Teachers in General Practice, EURACT in 2005) focus on a biopsychosocial perspective. So core values in primary care include a holistic patient-centred approach. There has been much debate over the definition of patient-centredness and its measurement, but Stewart defines essential components as: exploring the patient’s reason for the visit, including their information needs and concerns, seeking an integrated understanding of the patient’s world, finding common ground on defining the problem and how to manage it, attending to health promotion and prevention, and enhancing the on-going patient-doctor relationship. This paradigm change from biomedical and disease-centred, is embodied in ‘the patient-centred clinical approach’. Patient-centredness, although a widely recognized concept, is difficult to define, and measure.

The importance of communication The consultation is the pivotal exchange in health care delivery. Silverman reports that during their working life doctors perform 200,000 consultations. Striving for quality in such a fundamental area is therefore a professional imperative. Research continues to show that doctors fail to determine why their patients really consult. Studies have shown how quickly doctors interrupt patients, how they fail to elicit half of their concerns and how important unvoiced agendas are. Doctors often consult in a directive doctor-centred style. Patients crave information and want to be involved in decisions regarding their care. Problematic communication has led to malpractice claims and dissatisfaction.

Pragmatic process and outcome measures Time is used as a crude measure of consultation quality and studies have shown that longer consultations are associated with improved problem recognition. Studies have also shown that a “patient –centred” approach to the medical consultation does not always take longer -it is the interplay of factors that is important. Mechanic has pointed out the complexity of potential “active ingredients” in consultations which impact on time and quality (variability in problems, patients, doctors, the system). 124

World Book of Family Medicine – European Edition 2015 Our understanding of effectiveness needs to be further developed. Patient satisfaction surveys have flourished and many are now available. Baker defined satisfaction as “the patient’s judgement of the quality of care”. Both Ware (in the US) and Baker (UK) found that technical and interpersonal aspects of care are important for satisfaction. Patient satisfaction studies confirmed that remarkably few patients express dissatisfaction, which may be because satisfaction becomes a composite of overall attitude to health care and specific feelings. Framing may be influenced by methodological approaches. In satisfaction studies there was downward drift over time, which could be linked to increasing patient expectations and staff demoralisation, so repeated surveys could become problematic. Calnan has investigated patient satisfaction with general practice in the UK (95%), Greece (87%), Yugoslavia (85%) and Russia (62%): all nominated the doctorpatient relationship, and professional skills as important. Another of his surveys reported that despite patient satisfaction being high, 38% of respondents felt unable to discuss personal problems with their GP, which casts doubt on satisfaction denoting quality of care. Satisfaction surveys have limitations as patients seem inclined to report satisfaction and the results of such surveys fail to provide detail needed for assessment of individual consultation quality. Patients may report satisfaction with their consultation, but have they been helped?

The Patient Enablement Instrument The development of the Patient Enablement Instrument (PEI) aims to operationalise patient-centred consulting in terms of a patient-reported outcome. It represents over 20 years work by Howie (1) and was developed from literature review and patient focus groups: six questions were discriminatory (Figure 1). The Patient Enablement Instrument As a result of your visit to the doctor, do you feel you are ... Much Better Same Not better or less applicable able to cope with life able to understand your illness able to cope with your illness able to keep yourself healthy

⃝ ⃝ ⃝ ⃝ Much more

⃝ ⃝ ⃝ ⃝ More

⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ Same Not or less applicable

confident about your health ⃝ ⃝ ⃝ ⃝ able to help yourself ⃝ ⃝ ⃝ ⃝ Scoring: much better/more: 2; Better/more: 1; Same or less: 0; Total score: max 12, min 0, per consultation Figure 1: The Patient Enablement Instrument (PEI) Enablement builds on theories that adjustment and coping are important modifiers of patient outcome, and predictors of how patients feel and perceive life. Although enablement correlates with satisfaction measures, it represents a distinct concept. GPs who were more enabling were those who had longer consultation times, so both were regarded as useful measures of consultation quality. It is known that continuity (how well the patient knows their GP) improves enablement (and is under attack by contemporary service development). Studies relate enablement and empathy (2) , and an analysis of verbal interactions in consultations (3) showed that socio-emotional interactions support enablement. Receiving a prescription when one is expected (4,5) is also associated with enablement. Mead et al studied a modified PEI (part of the General Practice Assessment Questionnaire (GPAQ 12) in the UK, with 190,038 consultations, 1031 practices) and found patients’ evaluation of communication skills was associated with enablement. Patients with chronic illness and frequent attenders report lower enablement, and patients consulting in other languages report higher enablement (5). The PEI has been validated in Poland (5) Croatia, Thailand, Japan, China and Sweden with similar results. Howie’s study reported PEI as independent of case-mix (4), but Mercer and Pawlikowska (5) have found that those with psychological problems are more difficult to enable. A wide variety of issues impact on the consultation, given the influence of case-mix, the individuality of patients, 125

World Book of Family Medicine – European Edition 2015 doctors and their relationships, it is clear that any quantitative measure of effectiveness based on the analysis of small numbers of consultations, will be unlikely to yield a reliable measure. Large numbers of unselected consultations are needed for the effect of influences to accumulate. PEI requires such conditions, which is both its strength and its possible limitation. Patient enablement (the PEI) provides us with a way to investigate effectiveness in general practice, which is sensitive to patient, doctors and consultations. It encapsulates general practice core values and a patient-centred approach.

Take home messages 

Increasing patient involvement in the assessment of their own care is a 21st Century imperative.



The medical consultation is pivotal to health care delivery, and the pursuit of excellence in consultations enables practitioners to activate their knowledge in the service of patients.



There are many ways to approach the assessment of effectiveness, and patient centred outcomes are valued, but sometimes difficult to define and operationalise.



The Patient Enablement Instrument (PEI): Patient offers an approach to investigate effectiveness in family practice, which is sensitive to patient, doctors and consultations.

Original abstract http://www.woncaeurope.org/content/theme-c-measuring-effectiveness-general-practice-family-medicine

References 1. 2. 3. 4. 5.

Howie J, Heaney D, Maxwell M. Measuring quality in general practice. Occas Pap R Coll Gen Pract. 1997; 75:32. Mercer S, Reilly D, Watt G. The importance of empathy in the enablement of patients attending the Glasgow Homoeopathic Hospital. Br J Gen Pract. 2002; 52(484): 901-5. Pawlikowska T, Zhang W, Griffiths F, van Dalen J, van der Vleuten C. Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement. Patient Educ Couns. 2012 Jan; 86(1): 70-6. Howie J, Heaney D, Maxwell M, Walker J, Freeman G, Rai H. Quality at general practice consultations: cross-sectional survey. BMJ. 1999; 319: 738-43. Pawlikowska T, Nowak P, Szumilo-Grzesik W, Walker J. Primary care reform: a pilot study to test the evaluative potential of the Patient Enablement Instrument in Poland. Fam Pract. 2002; 19(2): 197-201.

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World Book of Family Medicine – European Edition 2015 Jean Karl Soler, MD, PhD [email protected]

41 – The International Classification of Primary Care: a Success Story Jean Karl Soler, MD, PhD Wonca International Classification Committee (WICC) Wonca Informatics Working Party (WIWP) Co-authors Marc Jamoulle 1,2, Peter Schattner 2 1. Wonca International Classification Committee (WICC) 2. Wonca Informatics Working Party (WIWP) (°) The first WICC working group consisted of Charles BridgesWebb (Australia), Robert Westbury (Canada), Philip Sive (Israel), Derek Callagher (New Zealand), Donald Crombie (United Kingdom) and Jack Froom (United States). ICPC was first developed by Henk Lamberts, Maurice Wood and Sue Meads.

The Forty Year Story of ICPC The WONCA International Classification Committee (WICC) was set up by the WONCA Council in Melbourne in 1972 on the occasion of the Fifth World Conference (1). WONCA recognized the need for classifying and analysing data derived from clinical encounters with patients that was quite unique to family medicine. This would become increasingly important with the advent of electronic health records. From an initial small group led by Henk Lamberts and Maurice Wood (°), a tool which would become the ICPC was progressively developed and in 1987, the three existing classification systems, the International Classification of Health Problems in Primary Care (ICHPPC-2), ICPC-Process and Reason for Encounter - were merged into a single one; the ICPC. ICPC-2 was published in 1998 by the WONCA International Classification Committee, after several years of revision and cross-mapping with the International Classification of Diseases (ICD) – 10 (2). ICPC-2 is maintained by WICC and an updated version is edited on the site of the Norwegian Centre for Informatics in Health and Social Care. WICC members meet each year in a different country and communicate through a very active mailing list.

ICPC and its Role in Primary Care ICPC is a coding and classification system that reflects the distribution and content of the domain of family medicine, and also acts as its ordering principle. It was designed as an epidemiological tool to classify and analyse data about three important elements of the health care encounter: the reasons for encounter (RFE), the diagnosis or problem, and the process of care in family medicine. Novel features are the inclusion of patients’ symptoms and complaints which allows the patient's reasons for encounter to enter a system of routine clinical data collection, the structuring of data into episodes of care, and the incorporation of the symptom as a diagnosis (3). The collation and analysis can occur at the level of an individual patient for clinical care, and at the practice level for recall, clinical audit and activity analysis for health services research. Maps are maintained from other classifications such as ICD-10 so that ICPC may also be used as an organizing principle for data collected in other systems such as the clinical terminology, SNOMED-CT. Linkage of elements permits categorization from the beginning of the encounter with a health problem to its conclusion, as well as a dynamic arrangement of encounters into episodes. ICPC-2 is available in more than 25 languages. It is compact, and the entire classification can fit onto two A4 pages. It is compatible with problem-oriented clinical records. In Norway, FDs are obliged to label all fee-for-service bills, sick-leave certificates and social security forms with an ICPC-diagnosis in order for them to be accepted by the health authorities. It is also used in referrals, e-Prescriptions and the

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World Book of Family Medicine – European Edition 2015 electronic ordering of laboratory tests (4).

ICPC Use in Family Medicine Research ICPC has been used extensively for research in family medicine. In Australia, a version of ICPC is used in the BEACH database which contains more than 1,400,000 FD-patient encounter records (5). In the Netherlands and Malta, researchers are able to create reports from TransHis (6), an ICPC-based electronic health record, and the data have been used to develop the first public domain database of the predictive power of symptoms in making a diagnosis, for all relevant primary care diagnoses. ICPC is used by Danes conducting research in rural practice (7), as well as FDs who enter data into the Danish General Practice Research Database (8).

The Future of ICPC A workshop on ICPC and other classification systems was conducted at the 2010 WONCA Europe conference in Malaga, Spain between WICC and the WONCA Informatics Working Party (WIWP). WIWP is primarily concerned with education in the field of family medicine informatics. Meanwhile, WICC is developing the third version of ICPC. ICPC-3 has been in development for many years, using data collected with ICPC and other coding systems to allow expansion and modernisation of the classification without losing its core characteristics and values. Further information is available at www.ph3c.org , including the ICPC training module and an extended bibliography.

Take Home Messages 

Structured data in electronic health records are important not only for education but also for research and audit purposes



Several classification systems are available, including the International Classification of Primary Care (ICPC) produced by WONCA



Revising ICPC and getting more family physicians skilled in its use remain ongoing challenges

Original Abstract http://www.woncaeurope.org/content/ws-17-international-classification-primary-care-icpc-and-hows-and-whys-classification

References 1. 2. 3. 4. 5. 6.

7. 8.

Westbury RC. A classification for family medicine. Can Med Assoc J. 1976 Aug 7;115(3):202. PubMed PMID: 20312758; PubMed Central PMCID: PMC1878637. Okkes I, Jamoulle M, Lamberts H, Bentzen N. ICPC-2-E: the electronic version of ICPC-2. Differences from the printed version and the consequences. Fam Pract. 2000 Apr;17(2):101-7. Erratum in: Fam Pract 2000 un;17(3):275. PubMed PMID:10758069. Bentsen BG, Hjortdahl P. Why do people contact physicians? The development of the core classification of primary health care. Tidsskr Nor Laegeforen. 1991 Sep 30;111(23):2867-70. Norwegian. PubMed PMID: 1948889. Karlstad O, Nafstad P, Tverdal A, Skurtveit S, Furu K. Comorbidities in an asthma population 8-29 years old: a study from the Norwegian Prescription Database. Pharmacoepidemiol Drug Saf. 2011. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21953881. Harrison C, Britt H, Miller G, Henderson J. Prevalence of chronic conditions in Australia. PLoS One. 2013;8(7):e67494. doi:10.1371/journal.pone.0067494. Jean K Soler; Inge Okkes; Sibo Oskam; Kees van Boven; Predrag Zivotic; Milan Jevtic; Frank Dobbs; Henk Lamberts; The Transition Project. An international comparative family medicine study of the Transition Project data from the Netherlands, Malta and Serbia. Is family medicine an international discipline? Comparing diagnostic odds ratios across populations. Family Practice 2012; doi: 10.1093/fampra/cmr099. Klinis S, Markaki A, Kounalakis D, Symvoulakis EK. Monitoring Reasons for Encounter via an Electronic Patient Record System: the Case of a Rural Practice Initiative. Int J Med Sci 2012; 9(8):704-707. doi:10.7150/ijms.4999. Available from http://www.medsci.org/v09p0704.htm Thomsen, R. W., Friborg, S., Nielsen, J. S., Schroll, H., & Johnsen, S. P. (2012). The Danish Centre for Strategic Research in Type 2 Diabetes (DD2): organization of diabetes care in Denmark and supplementary data sources for data collection among DD2 study participants. Clinical epidemiology, 4(Suppl 1), 15.

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World Book of Family Medicine – European Edition 2015 Janet Christie-Seely, MD [email protected]

42 – Physician Heal Thyself and then the World: Workaholism, Helpaholism and other Physician Conditions (Fraud Syndrome, Empathopoenia, Email-Overdose, MDeity Syndrome, Cell-phone-Otitis, etc) – Playful but Effective Medications for Serious Symptoms Janet Christie-Seely, MD, FCFP, Professor of Family Medicine, University of Ottawa, Ontario, Canada. Family Therapist

Most docs are workaholics or helpaholics -- especially Family Docs (1)! I am both. I still run workshops and a psychotherapy practice at 75. I love what I do, that’s the problem! I’m getting better! I read Barbara Killinger’s “Workaholics: the Respectable Addicts; a Family Survival Guide” (2), often worse in its impact than alcoholism. Take the Workaholic Quiz at: www.cnn.com/interactive/2011/05/living/workaholic.test/ and find out if your case is serious! I was fortunate to train with Virginia Satir, the “Columbus of Family Therapy”, an enlightened lady way ahead of her time. Stone deaf for two years from mastoiditis at six, she noticed people looked very different when communicating, and planned to become a detective on parents when she grew up. Her mother, a Placator never spoke her own feelings, hid anger deep inside, never saying “No!”– like many family docs. Her father was a Blamer, hiding his helplessness and shame of alcoholism. Others looked like computers, the Super-Reasonables –- maybe she met some doctors (specialists particularly) -- hiding discomfort about feelings (“Just give me the facts. Don’t bother me with this emotional stuff!”), quoting N.E.J.M or the Bible. Others were always joking or changing the subject, the clowns hiding despair, the Distracters. She later understood these four came from AND increase Low SelfEsteem (3). So one medication that helps stop the Performance-Based Self-Esteem of most physicians is the prescription of:

Congruence! I remember being told to be congruent with patients in Med School, but nobody explained how! Congruence is being respectful, considerate and honest. Non-verbal signals match verbal content. If you’re angry you may look and sound angry, but you don’t blame or accuse, you try to understand the other’s position.

HIGH SELF-ESTEEM

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World Book of Family Medicine – European Edition 2015 Every communication has three components: Self - one’s thoughts, feelings and opinions, Other’s thoughts, feeling and opinions, and the Context or situation. Picture a peace sign, without the bottom bar, and you have congruence - all three are expressed. When feeling safe and confident (high Self-Esteem), it’s easy to be congruent AND it adds to the self-esteem of both parties. For example; “Mrs Smith. I see you are fed up with the side-effects, and I’m getting frustrated with you ‘forgetting’ the pills, because you really need them. Can we discuss this situation so we get unstuck?” When you feel insecure or defensive you move to one of those Stances, which make you feel a victim, a jerk, a cold fish or a clown respectively, i.e. you feel even worse about yourself underneath the anger, apologies, quoting of studies or joking. They are “survival stances” as that’s how you learned to survive in your family growing up. Each coping stance ignores part of the picture:

Stance:

PLACATING

Each hides Feelings:

(ANGER )

BLAMING

SUPER-REASONABLE OR COMPUTER

(HELPLESSNESS)

(FEAR OF FEELINGS)

DISTRACTING OR IRRELEVANT (DESPAIR)

LOW SELF-ESTEEM

Icebergs Virginia often said: “The problem’s not the problem, it’s the coping”. What are we coping with? The insecure feelings the problem generates. Behaviour is the tip of an iceberg (4) - the only part seen. It pays, especially for physicians to know the other layers. Humans, like icebergs are all unique and beautiful, but the layers under the waterline can be dangerous. Below Behaviour, determining it, are the Coping Stances described above. Fuelling them are Feelings, especially feeling about ourselves – our Self-Esteem. We developed that from Perceptions of ourselves from childhood experiences. If we came to expect criticism and punishment, that’s what we continue to dole out to ourselves -- what we in the Ottawa Satir Learning Centre call our Gremlin (from a wonderful little book: ”Taming Your Gremlin:” (5)). The Gremlin loves Negative Self-Talk, and lives in the Expectation or “Should-ing” layer. First homework: Draw your Gremlin (did he or she just say: “But you can’t draw!” – a scowly-face or a cut out tiger from a magazine will do, but it should be visual on a piece of paper). Carry this around for several days, recording anything it says, like: “You’re lazy / a fraud / way behind in your journals / etc”. Beware; doctors’ Gremlins are louder than most! Then, for another week, try elastic band therapy - wear one on your wrist - every time you hear the little fellow give it a flick – not too hard, this is NOT self-punishment! Under the Expectation layer is “Yearnings” – what we really want and need in life –to love and be loved, to be heard, to contribute. How often do you listen to yourself rather than patients? Have you ever talked to the kid inside you who longs to play, paint, dance or research something? Second homework: dialogue with him or her, with a pen or a pencil in your non-dominant hand for the child. (When I tried I was startled at what I heard – from a three year old whom I’d told was not good enough! She loves painting! www.christie-seely-art.ca ). Diving into Yearnings propels you into the Self or “I AM”, your spiritual core. Good news! Here, your self-esteem is always high, and you can readily say: “The world is a better place because I am in it!” Try saying that to yourself now – without thinking in terms of your work contributions. You can also get to Self through meditation, music, art, running – but if you go through the Iceberg you can learn to live there. It will improve your ability to heal the world!

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Good luck!

Take home messages 

True self-esteem is independent of performance.



Congruence raises self-esteem of all concerned.



Listen to your inner kid, don’t berate him / her.



Satisfy YOUR real needs, THEN help the world.

Original abstract http://www.woncaeurope.org/content/3798-physician-heal-thyself-and-then-world-workshop-workaholism-helpaholism-andother

References 1. 2. 3. 4. 5.

Janet Christie Seely, author-editor.: Working with the Family in Primary Care: A Systems Approach to Health and Illness. Chapter 31: The Physician’s Family. Praegar. 1984 Barbara Killinger: Workaholics; the Respectable Addicts. A Family Survival Guide. Key Porter books Ltd. 1991 Virginia Satir, The New Peoplemaking, Palo Alto, CA:Science and Behaviour Books, Inc. 1988 Virginia Satir, John Banmen, Jane Gerber, Maria Gomori: The Satir Model: Family Therapy and Beyond. Palo Alto. CA. Science and Behaviour Books Inc. 1991 Richard Carson: Taming Your Gremlin, A Guide to Enjoying Yourself. Dallas, Texas. The Family Resource, Inc. 1983

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World Book of Family Medicine – European Edition 2015 David E.J. Bazzo, M.D., FAAFP, CAQSM [email protected]

43 – Competency in Medical Record-Keeping: Development of a Scale and Assessing CME (CPD) Impact David E.J. Bazzo, MD, FAAFP, CAQSM Clinical Professor of Family Medicine, University of California, San Diego, School of Medicine Director, Fitness for Duty Program, UCSD PACE Program Co-Director, Primary Care Core Clerkship Co-authors: William J. Sieber, PhD, William A. Norcross, MD , Sara FernandesTaylor, BA, University of California, San Diego Physician Assessment and Clinical Education (PACE) Program

Poor medical record keeping is a commonly encountered deficiency when evaluating physician quality. Medical records that do not adequately or accurately capture what transpired between the provider and patient at the time of an interaction lead to poor communication, medical errors and lawsuits. The University of California, San Diego, Physician Assessment and Clinical Education (PACE) Program has been offering assessment and remediation of physicians in all specialties since 1996. Early in the course of our assessment program, it became clear that deficient medical records were a common theme for many referred participants. Further needs assessment work revealed that only a small minority of physicians ever received formal training in medical record keeping. A surprising finding since a medical record entry must be made for every patient interaction. PACE therefore developed the Medical Records Keeping Course (MRKC) and initially offered it in 1999. Similarly, PACE offers continuing education courses in prescribing, physician-patient communications, professional boundaries, anger management and customized courses. A number of the ACGME/ABMS Core Competencies (Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism and Systems Based Practice) particularly interpersonal and communication skills, and professionalism address medical record keeping. It is an integral and necessary part of the practice of medicine. The medical record serves as a source of communication, is used to help determine the quality of patient care, is used to confirm proper reimbursement and is the key source of evidence in medical risk management matters. The PACE MRKC content covers: an introduction to medical records and a brief history of the modern day record; the legal requirements and aspects of the medical record; coding, billing and compliance regulations; computer hardware and software information related to the record; information retrieval, information security, privacy and HIPAA ; and, the electronic health record. Acquisition of knowledge, skills or attitudes is the goal of any educational endeavour. To measure the success of knowledge acquisition, the PACE MRKC course has pre-tests and post-tests. Knowledge (competence) must be achieved prior to incorporating items into practice (performance). Knowledge, the precursor to practice, is easier to assess and became our initial objective. The participants of the PACE MRKC were generally mandated to attend the course by a state regulatory board, hospital or medical group based on a disciplinary action. In the sample, one hundred seventy-two participants took the pre- and post-test. A comparison group/convenience sample of thirty-two non-disciplined UCSD Family Medicine residents and faculty were recruited. A thirty item multiple-choice test was devised covering the content areas of “legal/ethical, electronic health record and coding.” Principle components factor analysis demonstrated a strong one factor

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World Book of Family Medicine – European Edition 2015 solution. An independent three factor solution was tested but there was weak statistical support for the three factor structure. Cronbach’s alpha was 0.72, with 30 items indicating internal consistency. The MRKC participants scored 21.2 on the pre-test and 24.7 on the post-test. The UCSD faculty scored 24.3 on the pretest and 25.3 on the post-test and the UCSD residents scored 23.1 on the pre-test and 24.0 on the post-test (figure 1). There was significance difference between comparison groups with the MRKC physicians scoring significantly lower than the UCSD groups on the pre-test (p